Point of View

POINT OF VIEW

Adib D. Jatene

Hospital do Coração – ASS – São Paulo, SP - Brazil

^{Mailing Address}

Upon graduating from FMUSP (University of São Paulo Medical School) in 1953, as of 1958 I had the good fortune of working with Dante Pazzanese, creator of the Instituto de Cardiology do Estado that now bears his name (Dante Pazzanese Institute of Cardiology – São Paulo). Dr. Dante, a visionary, had it clearly in mind that any public health entity would find it very difficult to survive and flourish were it to rely exclusively on funds allocated to it in the public budget. The public budget, always drawn up in the previous calendar year, chronically insufficient and subject to contingencies, never manages to ensure a volume of funds capable of transforming such an entity into a leading institution that generates groundbreaking knowledge. Because of his foresight, Dr. Pazzanese requested and obtained then Governor Jânio Quadros’ approval for the creation of a Research Fund made up of funds raised by means of donations from various sources and by charging for services rendered. Service costs were published in the Official Gazette and six social service client categories were established. Category A, which represented approximately 60% of total clients, paid nothing. Category C paid the full price, and Category B was divided into four subcategories that paid, respectively, 10, 20, 40, or 60% of the established price for the services rendered. The Fund was idealized as a bank account managed directly by the institution’s directors and was not included in the budget drawn up by the São Paulo State Finance Department. These were extrabudgetary funds that could be made available with the promptness necessary for the institute to stay apace with scientific and technological advances.

The success of this initiative encouraged other official state institutes to create their own Research Funds, the resources of which were allocated basically to personnel, supplemental income, research funding, travel expenses for attendance at international congresses, internships abroad, and other activities not normally taken into account when drawing up the budget, but vital to the institutional, and consequently scientific development of any country – and furthermore, without the habitual bureaucratic restrictions, thus lending flexibility to the institute’s activities. In 1966, the Research Fund provided funds to cover Dr. Eduardo Souza’s request for a two-month internship in Cleveland to familiarize himself with coronary angiography techniques. The funds were made available in one week. Dr. Sousa’s return, with all the necessary equipment acquired in record time, rendered the institute a position of leadership. Brazil was the second country in the world to begin coronary artery bypass graft surgery.

Over a period of nearly 20 years, this tool – the Research Fund – was one of the mainstays responsible for the scientific advance achieved by the research institutes of the State of São Paulo, such and the Instituto Agronômico de Campinas, Butantã, and the Instituto Biológico, among many others.

Unfortunately, in the late ‘70s, the State Finance Department, in the course of an administrative restructuring program, decided to extinguish the Research Funds, replacing them in each and every institution with the Special Expenses Fund, with two major innovations: 1) the Fund came to be considered an item of the public (State) budget; and 2) the institutes were no longer allowed to use Fund resources to pay personnel.

This change constituted a major setback. The institutes struggled for years to reinstate the original Fund model. I myself took part in various public hearings held at the State Legislature, but to no avail.

In 1978, when Instituto do Coração was begun, Professor Zerbini, another visionary, proposed the creation of a Support Foundation. The foundation, virtually a recreation of the former Research Fund, was set up and now carries Dr. Zerbini’s name. All proceeds from medical services rendered by the institution were channeled into the Support Foundation. These proceeds were used mainly to cover payroll expenses, clinical and basic research, and also to help pay for InCor maintenance and equipment. Medical care, rendered predominantly (80%) to patients covered by the public Unified Health System (SUS), was then extended to clients of private health insurance plans and out-of-pocket payers. In the ‘90s, when I was still active in the institute, only one-third of the expenses were covered by the public budget. Funds raised by the Foundation covered the other two-thirds. Of the two-thirds raised by the Foundation, 40% came from services rendered to SUS patients who accounted for 75 to 80% of total services rendered. The remaining 60% of funds raised by the Foundation came from the 20 to 25% of services rendered to clients of private health insurance plans and out-of-pocket payers. It was thus possible for the institute to hold on to full time personnel and virtually eliminate turnover by keeping remuneration of technical personnel at the labor market level.

The performance of InCor – which throughout its 30 years of activity has always been considered one of the world’s most important institutes of cardiology with outstanding participation in international events – is, with all certainty, due to the institutional arrangement that made it a competitive hospital. I define a competitive hospital as one that is sought out not only by those who have no alternative, but also by those who are able to choose. And they choose it, not because it is free, but because it is good. The InCor research laboratories compete on an equal footing with the best in the world in basic research on heart conditions such as that undertaken in the arteriosclerosis lab, as well as research carried out in the immunology and genetic engineering labs, among others, considered the most advanced in the country. Both the clinical treatment provided, which incorporates all the most modern technology, and the interventional and surgical techniques boast international recognition.

This institutional arrangement is being copied by many research institutions and university hospitals that are redeeming their performance, as is demonstrated by Instituto Butantã which, thanks to its support foundation, is now contributing to the government’s self-sufficiency policy in the production of immunobiological products.

The strategy employed – a public service entity with its own support foundation – is essential not only to InCor, currently held to be a true national heritage asset, but for the country. It is undoubtedly the type of management engineering that makes institution directors responsible for conquering ongoing improvement, where labor-claim rhetoric gives way to proposals that aimed to solve institutional problems and featured keen involvement on the part of all the various employee categories.

Proof that the model works is the fact that in InCor’s 30 years of existence it has never experienced one single strike – eloquent confirmation that the major scientific and technological advances achieved have been accompanied by ongoing improvement in administration and management. Such results are worthy of reflection on the part of all those interested in redeeming the country’s health services.

The InCor model served as inspiration to the rest of the hospital complex in creating the Medical School Foundation. As of its implementation, the cycle of strikes at Hospital das Clínicas was halted, showing that the labor claims that went unheeded – the reason for the strikes – were legitimate and no new labor claim movements were triggered after the Foundation met employee demands.

Upholding and consolidating such an arrangement is thus essential for an institution such as InCor that, thanks to this Support Foundation arrangement, has risen to the position it now occupies – that of a national heritage asset.

Manuscript received January 19, 2007; accepted January 23, 2007.

Mailing Address:

Adib D. Jatene

Hospital do Coração

Rua Desembargador Eliseu Guilherme, 147

04004-030 – São Paulo, SP - Brazil

E-mail: [e-mail]

Manuscript received January 19, 2007; accepted January 23, 2007.

Publication Dates

• Publication in this collection
  21 May 2007
• Date of issue
  Mar 2007