Management strategies to expand access to supply of specialized services in the municipality of Rio de Janeiro, Brazil, between 2021 and 2024

Abstract

This study is to describe the management models adopted by the capital city of Rio de Janeiro in the area of health units between 2021 and 2024. An ecological, time-series, descriptive study was carried out using public data from official systems and documentary analysis of formal partnership instruments signed by the Municipality of Rio de Janeiro. The results were presented by identifying the problem situation for each level of care and the alternative management model adopted by the Direct Administration. The evolution of health indicators during the period of change in management was analyzed. The Social Health Organizations model was resumed in the management of all Primary Health Care (PHC) units, with a return to PHC coverage and complete teams. In specialized care, Civil Society Oganizations were hired to set up surgical specialty centers in hospital units, with a five-fold increase in the number of surgeries offered. In hospital care, two models have gained prominence: the Municipal Public Company and the Public-Private Partnership.

Key words:
Health services management; Public Health System; Management Models; Public-Private Partnership

Resumo

O presente estudo objetivou descrever os modelos de gestão adotados pela capital fluminense no âmbito das unidades de saúde entre os anos de 2021 e 2024. Realizou-se estudo ecológico de série temporal e descritivo, a partir de dados públicos dos sistemas oficiais e análise documental de instrumentos formais das parcerias firmadas pelo Município do Rio de Janeiro. Foram identificadas as situações problema para cada nível de atenção e o modelo de gestão alternativos à Administração Direta adotado. A evolução dos indicadores de saúde no período de mudança de gestão foi analisada. O modelo por Organizações Sociais de Saúde foi retomado na gestão de todas as unidades da Atenção Primária à Saúde, tendo sido observada a retomada da cobertura de Atenção Primária e das equipes completas. Na atenção especializada, houve contratações de Organizações da Sociedade Civil para implantação de centros de especialidades cirúrgicas nas unidades hospitalares, cuja oferta cirúrgica quintuplicou. Na Atenção Hospitalar, dois modelos ganharam destaque: a Empresa Pública Municipal e a Parceria Pública Privada. Os resultados não podem ser diretamente ou exclusivamente atribuídos à estratégia de gestão adotada, devendo novos estudos serem desenvolvidos.

Palavras-chave:
Gestão de serviços de saúde; Sistema Público de Saúde; Modelos de Gestão; Parceria Público Privada

Resumen

El objetivo de este estudio es describir los modelos de gestión adoptados por la capital de Río de Janeiro en el ámbito de las unidades de salud entre 2021 y 2024. Se realizó un estudio ecológico, de series temporales y descriptivo, utilizando datos públicos de los sistemas oficiales y análisis documental de los instrumentos formales de asociación firmados por el Municipio de Río de Janeiro. Los resultados se presentaron identificando la situación problemática de cada nivel de atención y el modelo de gestión adoptado como alternativa a la administración directa. Se analizó la evolución de los indicadores de salud durante el período de cambio de gestión. Se retomó el modelo de las Organizaciones Sociosanitarias en la gestión de todas las unidades de Atención Primaria, con la vuelta a la cobertura de la Atención Primaria y a los equipos completos. En la atención especializada, se contrataron Organizaciones de la Sociedad Civil para montar centros de especialidades quirúrgicas en las unidades hospitalarias, quintuplicándose la oferta de cirugías. En la atención hospitalaria, dos modelos han ganado protagonismo: la Empresa Pública Municipal y la Asociación Público-Privada. Los resultados no pueden atribuirse directa o exclusivamente a la estrategia de gestión adoptada, por lo que deben realizarse nuevos estudios.

Palabras clave:
Gestión de servicios sanitarios; Sistema Sanitario Público; Modelos de Gestión; Colaboración Público-Privada

Introduction

The 1988 Brazilian Federal Constitution (Constituição Federal - CF), in its articles on the Unified Health System (SUS), contemplated the participation of the private sector to complement health actions and services as a duty of the state. Even before the CF, providers of private or philanthropic clinics and hospitals were already providing services as entities contracted by the National Institute of Social Security (Instituto Nacional de Previdência Social - INPS)¹.

Later, other models for the use of services linked to the market or the so-called third sector were created in light of the advancement of ideas that advocate less participation by the state entity as a direct and exclusive provider of health care.

From the 1980s onwards, the performance of the public sector was identified as one of the most pressing problems of the international order, due to fiscal issues faced by almost all governments of central and peripheral countries, with deficits and debts that were growing. The rise to power of conservative governments in highly relevant countries on the world stage, such as the United States, England, and Canada, led to the predominance of the neoliberal diagnosis, strengthening the insertion of the free market in decisions regarding resource allocation².

This movement was consolidated in Brazil in 1995, with the implementation of the Master Plan for the Reform of the State Apparatus (Plano Diretor de Reforma do Aparelho do Estado - PDRAE)³, which culminated, among other milestones, in the creation of the legal entities of Social Organization (OS)⁴ and Civil Society Organization of Public Interest (Organização da Sociedade Civil de Interesse Público - OSCIP)⁵. It is well-known that the government of Fernando Henrique Cardoso (1995-2002) created the National Advertising Program, which strengthened the role of SOs and OSCIPs in health management. In the following governments, including those of Luiz Inácio Lula da Silva, the Private Law State Foundations (Fundações Estatais de Direito Privado - FEDPs) were created, maintaining the role of private entities in SUS. Thus, both right-wing and left-wing governments adopted these practices of partnership between the public and private sectors^6-9.

More recently, new legislation and regulatory frameworks have established possibilities for coordination, such as Public Private Partnerships (PPP)¹⁰, the Brazilian Hospital Services Company (Empresa Brasileira de Serviços Hospitalares - EBSERH)¹¹, Civil Society Organizations (CSOs)¹², and the Agency for the Development of Primary Health Care (Agência para o Desenvolvimento da Atenção Primária à Saúde - ADAPS)¹³. Other strategies by the Brazilian government have sought to support and speed up the provision of medical professionals in Primary Health Care (PHC), restoring the role of the public sector in providing direct health services, such as the More Doctors Program (Programa Mais Médicos - PMM)^14,15 and the Doctors throughout Brazil Program (Programa Médicos pelo Brasil)¹⁶.

All of these arrangements, intertwined in the structure and organization of the Brazilian health system, constitute mechanisms for joint action to overcome the immense challenges inherent to a universalist system. Managers who use partnerships with the market or civil society often justify them as a way to reduce bureaucracy and make processes more flexible, such as hiring human resources, structural works, or the purchasing of supplies, in addition to legal limits such as those established by the Fiscal Responsibility Law^17,18, which tend to be more complex and time-consuming in direct administration.

The use of such models as SOs in health has expanded significantly among subnational entities, especially in Brazilian capitals. São Paulo and Rio de Janeiro, with the largest populations in Brazil, have the largest number of SOs and establishments under outsourced management¹⁹.

In the city of Rio de Janeiro (MRJ), the adoption of alternative models to Direct Administration began with the Primary Health Care Reform in 2009²⁰, with a late expansion of PHC coverage, when compared to the other major cities throughout Brazil. The model of partnership with SO was used, resulting in a significant expansion of family health service (FHS) teams²¹. The Reform enabled a jump in PHC coverage from 7.34% in 2009 to 70.0% at the end of 2016¹⁷.

In 2021, after a serious management crisis faced between 2017 and 2020, coupled with the COVID-19 pandemic²², health regained its central position on the municipal political agenda with an increase in the budget, the renovation of units, the implementation of new units, and the restructuring of PHC teams²³.

Seeking to respond to the bottlenecks accumulated in the previous period and considering the new care needs arising from the post-COVID period, the Municipality of Rio de Janeiro diversified its public-private partnership models, seeking to expand the supply of health services and guarantee timely access to meet the immense pent-up demand.

In the resumption itself, aimed at expanding PHC coverage, the PMM and the SOs were called upon as important partners in management and service provision. In specialized care, the SOs support the management of super health centers, implemented in the areas of diagnoses, consultations, and ophthalmology referrals^24,25.

In hospitals, CSOs have taken on new services to combat long waiting times for elective surgeries and strategic procedures²⁶. The public company, Rio Saúde, was also an important player in enabling a new and powerful surgical center structure in a municipal unit.

Given the above, considering the volume and variety of management models in partnership with the private sector and civil society institutionalized in the Brazilian public health system, this study aims to map and describe the multiple management models adopted by the capital city of Rio de Janeiro, presenting the results through management indicators between 2021 and 2024.

Methodology

Study Design

This is an ecological, time-series, descriptive study on the management models adopted in the Municipality of Rio de Janeiro (MRJ) between 2021 and 2024, and the results of health indicators in the context of these management arrangements. For the 2024 data, the average for the year was used.

The study was divided into two stages: the first, with the survey of partnerships with outsourced entities implemented or continued by the management in the current term of 2021-2024, and the second, with results in indicators that represent the adopted management model (Chart 1). The indicators were included in light of the problem situation that motivated the adoption of each model, but this does not mean that the results were directly attributed to the adopted strategy.

Chart 1
Health establishments, management models/strategies, and selected indicators. MRJ, 2021-2024.

Unit(s)	Adopted Model(s)	Indicator(s)	Metrics	Reference	Source
Primary Care Unit	SO	PHC Coverage	Percentage	The last month of each year	E-management
Primary Care Unit	PMM	Number of complete teams	Number	The last month of each year	CNES
Souza Aguiar Municipal Hospital	PPP	Number of contracts	Number	The last month of each year	Souza Aguiar Hospital Complex (website: https://www.ccpar.rio/mapa/complexo-hospitalar-souza-aguiar/)
Centers specialized in hospital units	CSO	Oferta de cirurgias eletivas	Number	Annual average	SISREG Transparency Panel
Ronaldo Gazolla Municipal Hospital	Rio Saúde	Waiting time (hernia and gallbladder)	Days	Annual average	SISREG Transparency Panel

• Source: Authors.

The following indicators were selected: PHC coverage; number of complete teams; offer of elective surgeries; offer of hernia and gallbladder surgeries; and number of contracts.

Data source

Data was retrieved from official SUS systems, with public access, using following the sources: E-gestor, National Health Establishment Registration System (Sistema de Cadastro Nacional de Estabelecimentos de Saúde - SCNES), Outpatient Information System (OIS), and National Regulation System (Sistema Nacional de Regulação - SISREG). For the latter, the Municipal Health Department has a data management panel, enabling the presentation of the results used in this study in the indicators of availability of elective surgery, waiting time, and waiting line requests. Public data is made available in an aggregated and anonymized form in this environment²⁷.

Chart 1 shows which establishments, management models, and indicators were used in this study.

To survey the partnerships, 18 contractual instruments obtained from the official website of the Municipal Health Department of Rio de Janeiro were included in the study to identify the object, managed units, validity, adopted model, type of instrument, and names of the entities (Chart 2).

Chart 2
Health establishments, management models/strategies, and selected indicators. MRJ, 2021-2024.

Level of Care	Health Unit	Manage ment model	Object	Type of contractual instrument	Contractual instrument no.	Name of entity	Source
Primary Care	Primary Care Units - PCUs 10	OSS	Management, operationalization, and execution of health actions and services in the integrated healthcare territory within the scope of PA 1.0	Management Contract	006/2022	SPDM	https://saude.prefeitura.rio/ctgos/contrato-de-gestao/saude-da-familia/
Primary Care	Primary Care Units - PCUs 21	OSS	Management, operationalization, and execution of health actions and services in the integrated healthcare territory within the scope of PA 2.1	Management Contract	02/2021	GNOSIS	https://saude.prefeitura.rio/ctgos/contrato-de-gestao/saude-da-familia/
Primary Care	Primary Care Units - PCUs 22	OSS	Management, operationalization, and execution of health actions and services in the integrated healthcare territory within the scope of PA 2.2	Management Contract	003/2021	VIVARIO	https://saude.prefeitura.rio/ctgos/contrato-de-gestao/saude-da-familia/
Primary Care	Primary Care Units - PCUs 31	OSS	Management, operationalization, and execution of health actions and services in the integrated healthcare territory within the scope of PA 3.1	Management Contract	001/2021	VIVARIO	https://saude.prefeitura.rio/ctgos/contrato-de-gestao/saude-da-familia/
Primary Care	Primary Care Units - PCUs 32	OSS	Management, operationalization, and execution of health actions and services in the integrated healthcare territory within the scope of PA 3.2	Management Contract	007/2021	IDEIAS	https://saude.prefeitura.rio/ctgos/contrato-de-gestao/saude-da-familia/
Primary Care	Primary Care Units - PCUs 33	OSS	Management, operationalization, and execution of health actions and services in the integrated healthcare territory within the scope of PA 3.3	Management Contract	002/2021	SPDM	https://saude.prefeitura.rio/ctgos/contrato-de-gestao/saude-da-familia/
Primary Care	Primary Care Units - PCUs 40	OSS	Management, operationalization, and execution of health actions and services in the integrated healthcare territory within the scope of PA 4.0	Management Contract	001/2022	SPDM	https://saude.prefeitura.rio/ctgos/contrato-de-gestao/saude-da-familia/
Primary Care	Primary Care Units - PCUs 51	OSS	Management, operationalization, and execution of health actions and services in the integrated healthcare territory within the scope of PA 5.1	Management Contract	009/2021	GNOSIS	https://saude.prefeitura.rio/ctgos/contrato-de-gestao/saude-da-familia/
Primary Care	Primary Care Units - PCUs 52	OSS	Management, operationalization, and execution of health actions and services in the integrated healthcare territory within the scope of PA 5.2	Management Contract	002/2021	VIVARIO	https://saude.prefeitura.rio/ctgos/contrato-de-gestao/saude-da-familia/
Primary Care	Primary Care Units - PCUs 53	OSS	Management, operationalization, and execution of health actions and services in the integrated healthcare territory within the scope of PA 5.3	Management Contract	004/2021	SPDM	https://saude.prefeitura.rio/ctgos/contrato-de-gestao/saude-da-familia/
Specialized Care	Miguel Couto Municipal Hospital	OSS	Management, operationalization, and execution of health actions and services in Neurosurgery/Neurology, Cardiovascular Health, Telemedicine in Cardiology and Neurology, and management of CER Leblon	Collaboration Agreement	169/2022	FAS	https://saude.prefeitura.rio/ctgos/instrutivos-dos-termos-de-colaboracao/subhue/
Specialized Care	Francisco da Silva Telles Hospital	OSS	Management, operationalization, and execution of General and Urological Surgery actions and services	Collaboration Agreement	179/2022	VIVARIO	https://saude.prefeitura.rio/ctgos/instrutivos-dos-termos-de-colaboracao/subhue/
Specialized Care	Mariska Ribeiro Municipal Hospital	OSS	Management, operationalization, and execution of health actions and services within the scope of the Barata Ribeiro Municipal Hospital	Collaboration Agreement	001/2022	CEJAM	https://saude.prefeitura.rio/ctgos/instrutivos-dos-termos-de-colaboracao/subhue/
Specialized Care	Barata Ribeiro Municipal Hospital	OSS	Management, operationalization, and execution of Orthopedics and telemedicine actions and services	Collaboration Agreement	159/2022	FAS	https://saude.prefeitura.rio/ctgos/instrutivos-dos-termos-de-colaboracao/subhue/
Specialized Care	Piedade Hospital	OSS	Support for the management, operationalization, and execution of proctology and surgical gynecology actions and services, and endoscopic examinations	Collaboration Agreement	015/2022	VIVARIO	https://saude.prefeitura.rio/ctgos/instrutivos-dos-termos-de-colaboracao/subhue/
Specialized Care	Jesus Municipal Hospital	OSS	Support for the management, operationalization, and execution of pediatric surgery actions and services	Collaboration Agreement	013/2022	FAS	https://saude.prefeitura.rio/ctgos/instrutivos-dos-termos-de-colaboracao/subhue/
Hospital Care	Ronaldo Gazolla Municipal Hospital	Empresa pública	Hospital management, including ICU and clinical beds, and the Super Carioca Surgery Center.		251/2023	Public Company	https://saude.prefeitura.rio/contrato-de-gestao-com-a-empresa-publica-riosaude/
Hospital Care	Souza Aguiar Hospital Complex	PPP	Modernization and adaptation of building facilities and provision of non-care services at the Souza Aguiar Hospital Complex	Administrative Concession Contract	197/2023	PPP	https://www.ccpar.rio/mapa/complexo-hospitalar-souza-aguiar/

• Source: Authors.

Ethical aspects

This study uses exclusively public and anonymized secondary data, dispensing with assessment by the Ethics Committee.

Results

The analysis was divided into two stages: the first involved a documentary analysis of the public-private partnerships established by the Rio de Janeiro Municipal Health Department (Secretaria Municipal de Saúde do Rio de Janeiro - SMS Rio), between 2021 and 2024, to describe the adopted management model, according to the level of health care, and their respective formal adherence/contracting documents in force, showing the current situation of the partnerships established by SMS Rio.

At this point, the current situation of PHC, Specialized Care (SC) and Hospital Care (HC) was described based on 1) Problem: situation encountered by the SMS Rio management in 2021; 2) Proposed intervention: decisions made concerning the adopted management models; 3) The adopted management model; and 4) The current situation, which deals with the condition established by the management of the MRJ from 2021-2024, in an attempt to solve the initial problems encountered.

The second stage involves the analysis of the selected health indicators, considering that they are measurements needed to monitor the development of adopted actions, regardless of the current management models, considering that their results may also vary depending on administrative decision-making.

Five alternative management models to Direct Administration used by MRJ for the management of municipal health units from 2021 to 2024 (Chart 3) were identified. Within the scope of the documents analyzed in this study, MRJ provided a wide range of justifications for adopting each management model, depending on the type of unit and the structuring needs of each level of care.

Chart 3
Management models adopted by the Municipal Health Department of Rio de Janeiro, according to the problem situation identified in 2021, by level of health care.

Level of Health Care	Problem Situation (2021)	Intervention	Adopted management model	Documental source	Progress achieved (2024)
Primary Health Care	2019: Replacement of the OSS model for a Municipal Public Company in the 05 planning areas. 2020: 45.98% PHC coverage. 20% of the FHS teams are incomplete.	Resumption of management contracts by OSS in all program areas. The Municipal Public Company focused its activities on the hospital, emergency, and urgent areas. Restructuring and expansion of FHS teams mediated by the model. 2021-2023: expansion of the hiring of PHC doctors by OSS. Hiring of professionals through the Mais Médicos (More Doctors) Program.	Social Health Organization. Adherence to the Mais Médicos (More Doctors) Program resumed by the federal government in 2023.	e-Primary Care Manager: https://relatorioaps.saude.gov.br/ Management Contracts: https://saude.prefeitura.rio/ctgos/contrato-de-gestao/saude-da-familia/ National Registry of Health Establishments (CNES) Provisional Measure No. 1,165 of 2023 (Mais Médicos - More Doctors	Implementation of 03 new units. Renovation and adaptation of 237 existing units. Expanding coverage to 79% (04/2024). Reducing the number of incomplete teams (2024: 1% of total teams
Specialized Health Care	Long lines and waiting times for elective surgeries in general	CSO recruitment: implementation of 06 surgical specialty centers in hospital units	Regulatory Framework for Civil Society Organizations - MROSC	Law No. 13,019/2014	2024: quintuples the supply of elective surgeries.
Hospital Care	Long lines and waiting times for Hernia and Gallbladder surgeries (2021: 361 days)	Ronaldo Gazolla Municipal Hospital: - Adaptation of profile: from a reference for COVID-19 care, becoming the Super Carioca Surgery Center.	Ronaldo Gazolla Municipal Hospital: - Municipal Public Company.	SISREG Transparency Portal Management Contract 251/2023: https://saude.prefeitura.rio/contrato-de-gestao-com-a-empresa-publica-riosaude/	Ronaldo Gazolla Municipal Hospital: - August 2024: 61 days, average waiting time for elective hernia and gallbladder surgeries - 2023: performed 21,316 elective surgeries.
	Souza Aguiar Hospital Complex: - Low public investment in modernization and building maintenance; - High number of outsourced contracts for middle areas (gray coat). - Low efficiency in outsourced contracts.	Souza Aguiar Hospital Complex: - Grant by bidding for 30 years.	Souza Aguiar Hospital Complex: - Public Private Partnership (PPP).	SMS-PRO-2022/03013 - Administrative Concession Contract No. 197/2023 - Souza Aguiar Public Private Partnership (PPP): https://www.ccpar.rio/mapa/complexo-hospitalar-souza-aguiar/	No public documents were found on the gains obtained through this management model.

• Notes: The Souza Aguiar Hospital Complex, which includes, in addition to the hospital unit, the Regional Emergency Center of the Center and the Maria Amélia Buarque de Hollanda Maternity Hospital. The Bata Cinza PPP of the Souza Aguiar Complex includes the following services - Acquisition of Medical Equipment, Furniture, and ICT; Clinical Engineering - Maintenance, Hospital Logistics and Warehouse, Sterilization, Concierge, Reception and Parking, Solid Health Waste Logistics, Morgue, SAME, Surveillance and Property Security, Laundry and Linen, Nutrition (patients, companions and employees); Transportation: ambulance, stretcher bearers, Building Maintenance, Cleaning and Sanitation, Management of Prostheses and Orthoses (hospital logistics); IT and Telephony Maintenance, SESMT, Hospital Billing.
• Source: Authors, based on e-Gestor; CNES; City Hall of Rio de Janeiro: Management Contracts, Agreements, and Other Voluntary Partnerships; Management contract with the public company RioSaúde, Souza Aguiar Hospital Complex; Saúde Legis.

In the PHC context, the identified problems that justified the need to change the adopted management model include the reduction in PHC coverage, from 68.62% in 2016 to 45.98% in 2020, as well as the number of incomplete FHS teams (20% of the total). As of 2021, the OSS management model was resumed in 100% of all PHC units, including the substitution of the Municipal Public Company that was in force between 2019 and 2020 in five planning areas (PAs) of MRJ (PA 2.1/3.1/5.1/5.3/5.2).

It was possible to map the presence of four Social Health Organizations that share the management of PHC based on management contracts formalized with the Municipal Health Department, namely: Viva Rio (PA 2.2, 3.1, 5.2), GNOSIS (PA 2.1, 5.1), SPDM (PA 1.0, 3.3, 4.0, 5.3), and IDEIAS (PA 3.2).

The resumption of PHC coverage was observed, rising from 45.98% in 2020 to 79% in 2024, with a forecast for maintenance and adequation of PHC units, in addition to an increase in the number of complete FHS teams, according to the National Registry of Health Establishments (Cadastro Nacional de Estabelecimentos de Saúde - CNES).

The Regulatory Framework for Civil Society Organizations (Marco Regulatório das Organizações da Sociedade Civil - MROSC)¹² was the model used to expand elective surgical services in the city’s hospital units, which had been implemented in six units, to expand the following surgical specialties: general surgery, gynecological surgery, urological surgery, pediatric surgery, and orthopedic surgery.

In HC, two management models were explored during this period: the Municipal Public Company and the PPP. The Municipal Public Company was adopted in the management of the Ronaldo Gazolla Municipal Hospital, in the reconfiguration of the unit after the COVID-19 pandemic, a time when the unit was considered the main reference for COVID-19 in the city. The unit, with 245 Intensive Care Unit (ICU) beds and 83 surgical and day hospital beds, according to data from the National Registry of Health Establishments on October 25, 2024, became the largest unit in terms of the number of surgeries performed in the municipal health network, reaching 25% in 2023 and 22% by August 2024, according to data from the SUS Hospital Information System (data not shown).

By contrast, the PPP was implemented at the Souza Aguiar Municipal Hospital through Administrative Concession Contract No. 197/2023, signed on 11/6/2023²⁸, seeking to change the panorama identified until then regarding the low public investment in modernization and building maintenance, along with the high number and low efficiency of outsourced contracts (gray coat). No results resulting from this model were found, which can be explained by the time elapsed since its implementation (Chart 3).

Chart 2 complements the information on the management models that exist in MRJ in force in 2024 and analyzed in this study.

The partnerships described in Chart 1 were adopted or continued so that the identified problems could be resolved or mitigated, with results observed in relevant indicators, even though they may not evolve immediately or improvements that may be presented may not be attributed exclusively or directly to the interventions described.

For each adopted partnership, a monitoring indicator was listed for the respective process linked to the municipal management intervention. Measurements were made starting in 2021, reflecting the scenario assumed in the 2021-2024 term of office of the executive branch in the MRJ, up to the period with the most recent data available for this last year.

The monitoring indicators of the interventions carried out by SMS Rio in the 2021-2024 management cycle, when the interventions were implemented through different management models in partnership with Third Sector entities and a public company in the city of Rio de Janeiro, proved to be positive for all the indicators analyzed in this study, expect the assessment of the number of existing contracts at the Souza Aguiar Hospital Complex, which could not be assessed after the implementation of the PPP, as the public documents that portray the gains obtained by this adopted management model were not found. It should also be considered that the data on the production of hernia and gallbladder surgeries at the Ronaldo Gazolla Municipal Hospital, for the year 2024, appear to be lower than that observed in 2023, but these were calculated through a 12-month projection, based on information available up to August 2024. It is important to note that, in 2024, the supply of elective surgeries increased fivefold when compared to 2021, going from 22,234 in 2021 to 110,929 in 2024 (Chart 4).

Chart 4
Monitoring indicators for municipal management interventions. MRJ, 2021-2014.

Indicator	Period of analysis	2021	2022	2023	2024
PHC Coverage	Dec/2021 Dec /2022 Dec /2023 Apr/2024	61.9%	68.8%	68.7%	79.2%
Number of complete teams	Dec /2021 Dec /2022 Dec /2023 Apr/2024	1,037	1,208	1,293	1,344
Availability of elective surgeries	Annual quantity. 2024 (Jan-Sep): projected average for 12 months.	22,234	54,692	126,680	110,929
Production of hernia and gallbladder surgeries at the Ronaldo Gazolla Municipal Hospital	Annual quantity. 2024 (Jan-Aug): projected average for 12 months.	0	1,617	12,919	9,399
Number of contracts for the middle areas of the Souza Aguiar Hospital Complex	Number of outsourced contracts	65	65	1	1

• Notes: For PHC coverage, the calculation of the Potential PHC Coverage was considered, including the Family Health Teams (FHTs), Primary Health Care (PHC), Street Clinic Care (SCC), Riverside (eSFR), Prison Primary Care (PPC) teams, both those financed by the Ministry of Health at the national level, as well as the teams financed at the state, municipal, and Federal District levels with these entities’ resources, according to Technical Note N^o 301/2022-CGESF/DESF/SAPS/MS⁴⁹.
• Source: Authors, based on E-gestor⁴⁴, CNES⁴⁵, SIH⁴⁶, SISREG Transparency Portal⁴⁷, City Hall of Rio de Janeiro Transparency Portal⁴⁸.

Discussion

The diversity of legally established management models, in addition to Direct Administration (Social Organization, MROSC, PPP, Public Company) are strategies used to address problems in the public health system, in such a way as to provide the manager with the greatest resolution according to the profile and possibilities of action of the partnership adopted in a given political-economic context.

Among the benefits highlighted in the adoption of the management models presented in the study, efficiency, innovation, and cost reduction in the management of public services stand out, each model with its particularities, focused on optimizing resources and results²⁹. Despite this, there are important criticisms of these management models, considered an example of active privatization in Brazil, which transfers responsibilities from the public sector to private entities and raises concerns about the public management and transparency of resources, as well as questions about whether or not the rapid expansion of health coverage by reducing bureaucracy in fact results in a better quality of services^30-32.

The controversial discussion divides opinions, and studies on this topic reveal differing opinions, which makes it quite controversial. A systematic review of the literature on the Virtual Health Library showed that the advantages, such as those related to agility and flexibility in hiring personnel and the physical structuring of the system, are offset by the disadvantages related to the commercialization of health, difficulties in achieving agility and efficiency, fragmentation of the system, regulatory problems, lack of transparency, monitoring failures, limitations on innovation, high turnover of professionals, and impacts on the employment relationship³³. This is why it is important to implement actions aimed at resolving such problems in an attempt to form closer ties between the public and private sectors without compromising the public agenda.

Nonetheless, the adoption of OSS as a management tool for expanding the healthcare network corroborates the consolidation of this model as an alternative used by health system managers in most Brazilian states and municipalities. Currently, 25 of the 27 states of Brazil have this modality, which is also present in 275 municipalities throughout the country, predominantly in basic care units³⁴.

In the capital city of Rio de Janeiro, the resumption of coverage with a new increase in the population served, from 2021-2024, is in line with the findings of Costa et al.³⁵, who identified the disorganization of this level of care in the municipal government between 2017 and 2020. Processes, such as the so-called “Reorganization of Primary Care in the city of Rio de Janeiro - a project to optimize resources and strengthen the attributes of primary care”, which resulted in the reduction of the number of FHS teams, expressed the lack of priority for the health function in the government agenda during this period.

Regarding the use of the PMM to replenish incomplete teams, Giovanella et al.³⁶ identified the relevance of the program in addressing the shortage of professionals in areas of lesser interest and high turnover, as an important support for the Family Health Teams (FHTs) for stability in maintaining medical professionals in FHTs.

In MRJ, the arrival of approximately 200 doctors from the PMM contributed to the occupation of units that were difficult to adhere to, due to issues involving location or history of urban violence, reaching a status of only a 1% vacancy in 2024 (Chart 3).

In specialized care, elective surgeries stand out as one of the biggest obstacles to the comprehensive care recommended by SUS, aggravated by the recent scenario of the COVID-19 pandemic. The frequency of long waiting lists is essentially due to the insufficiency of hospital resources in the face of the demand for care, amplified by the loss of surgical production of up to 30% in Brazil in 2020 and 2021, when compared to 2019³⁷.

The execution of expanded surgical procedures through MROSC and the strategy of the Municipal Public Company at the Ronaldo Gazolla Municipal Hospital, provide a reduction in waiting times, which, when excessive, have unfavorable implications for the patient, the family, the professionals, the hospital, and society as a whole³⁸. The reduction in waiting times for hernia and gallbladder surgeries, reaching 61 days in 2024 (Chart 4), reaches parameters similar to the waiting times expected in developed countries³⁹.

Regarding the PPP model implemented at the Souza Aguiar Municipal Hospital, there is little time for it to be implemented so that the expected improvements can be measured, especially regarding structural reforms, acquisition of equipment and supplies, management of work processes, among other responsibilities assumed in the agreement. However, such advances as the centralization of contracts for the provision of support activities represent a rationalization of the process that favors aspects of control, transparency, auditing, cost-effectiveness, and monitoring of the execution of services.

There are still few studies describing PPPs in the health sector, including Brazilian cases. Challenges, such as balancing public and private interests, managing conflicts, and ensuring transparency, highlight the need for rigorous evaluation and monitoring to protect the integrity of public health, which can be biased by market interests⁴⁰. Positive examples of this type of partnership, when carried out with the necessary rigor, reinforce the successful aspects of choosing the PPP model, as in the case of the reduction of salt consumption in the United Kingdom, which highlights the importance of collaboration and monitoring of processes⁴⁰, as well as in the case of hospital management in a public unit in Bahia⁴¹, which highlights the choice of this model by managers due to the agility in purchasing and maintaining equipment, transparency in bidding, a single contract for managing several services, and control and accountability of the developed actions.

Although criticisms of the partnership models between SUS and the Third Sector are pertinent - especially considering that such models derive from neoliberal currents, which raises questions about possible conflicts of interest that may compromise the view of health as a state duty and a fundamental right of the population - it is necessary to consider the current situation of growing demands for health services, which require agile and efficient responses from the health system, given its direct relationship with the preservation of life. However, it is essential to consider the significant quality challenges faced by the Brazilian public health system and to improve the mechanisms for monitoring and evaluating these partnerships, as well as to strengthen the transparency of the contractual processes involved, ensuring the preservation of financial resources.

Conclusion

This article argues that changing environments favor social and health advances, not seeking to establish direct causal relationships, but rather to demonstrate how instability can influence political decision-making in public health. Kingdon⁴² and Oliver⁴³ state that unstable environments, such as crises and political changes, create windows of opportunity for advances in public policies, especially in the social and health areas, depending on the ability to identify and act in these moments, such as the facilitation of the implementation of public policies during the COVID-19 pandemic, and the creation of the National Health Service (NHS) in the United Kingdom, after World War II; or the political and social changes that forced coalitions of actors to respond to the HIV/AIDS crisis and the adoption of the Affordable Care Act (ACA, also known as Obamacare), driven by the economic crisis of 2008.

Thus, this article focused on the different management models adopted in the public health system of MRJ, aiming to strengthen the service provision capacity of municipal health units. Based on selected indicators, it was possible to demonstrate advances obtained in terms of the structure of the public health system in the same period in which the decision-making process to adopt different management models was implemented.

The results achieved in this study cannot, however, be directly attributed to the adopted management strategy, and this does not mean that the results are directly attributed to the adopted strategy. In this regard, caution should be exercised in interpretations, and it should be taken into account that health indicators may oscillate over time, depending on the actors involved, resources employed, and the control and evaluation mechanisms adopted to monitor Third Sector companies and other SUS partners.

Additional studies to assess the effectiveness of such strategies should be conducted, but this type of analysis requires a longer period to implement these to avoid confusion with other health measures related to strengthening SUS in the city of Rio de Janeiro, such as financing, continuing education of health professionals, among other variables. In addition, the analysis of results by the different management models implemented in this study, taking into account health facilities with similar characteristics and capabilities and from different Brazilian states, can contribute to understanding the effectiveness of the adopted strategies.

It is important to note that the management indicators evaluated in this study correspond to a random sample from a set of indicators related to health services with current management contracts with private entities, and that can be considered in future studies. In addition, other analyses that deal with more global indicators or even evaluate a larger number of indicators can contribute to the discussion on the participation of the Third Sector in Health.

References

• ¹ Matos CA, Pompeu JC. Onde estão os contratos? Análise da relação entre os prestadores privados de serviços de saúde e o SUS. Ciên Saude Colet 2003; 8(2):629-643.
• ² Diniz E. Governabilidade, governança e reforma do Estado: considerações sobre o novo paradigma. Rev Serv Publico 1996; 47(2):7-27.
• ³ Brasil. Ministério da Administração Federal e Reforma do Estado. Plano Diretor de Reforma do Aparelho do Estado. Brasília: MARE; 1995.
• ⁴ Brasil. Lei nº 9.637, de 15 de maio de 1998. Dispõe sobre a qualificação de entidades como Organizações Sociais e dá outras providências. Diário Oficial da União; 1998.
• ⁵ Brasil. Lei nº 9.790, de 23 de março de 1999. Dispõe sobre a qualificação de pessoas jurídicas de direito privado, sem fins lucrativos, como Organizações da Sociedade Civil de Interesse Público, institui e disciplina o termo de parceria, e dá outras providências. Diário Oficial da União; 1999.
• ⁶ Almeida C. Parcerias público-privadas (PPP) no setor saúde: processos globais e dinâmicas nacionais. Cad Saude Publica 2017; 33(Supl. 2):1-16.
• ⁷ Brasil. Lei nº 9.637, de 15 de maio de 1998. Dispõe sobre a qualificação de entidades como Organizações Sociais e dá outras providências. Diário Oficial da União; 1998.
• ⁸ Brasil. Medida Provisória nº 1.591, de 10 de novembro de 1997. Estabelece normas para parcerias entre o setor público e privado no setor de saúde. Diário Oficial da União; 1997.
• ⁹ Brasil. Projeto de Lei Complementar nº 92, de 2007. Dispõe sobre a criação de Fundações Estatais e outras providências. Câmara dos Deputados; 2007.
• ¹⁰ Brasil. Lei nº 11.079, de 30 de dezembro de 2004. Institui normas gerais para licitação e contratação de parceria público-privada no âmbito da administração pública. Diário Oficial da União; 2004.
• ¹¹ Brasil. Lei nº 12.550, de 15 de dezembro de 2011. Autoriza a criação da Empresa Brasileira de Serviços Hospitalares - EBSERH, e dá outras providências. Diário Oficial da União; 2011.
• ¹² Brasil. Lei nº 13.019, de 31 de julho de 2014. Estabelece o regime de colaboração entre a administração pública e as Organizações da Sociedade Civil. Diário Oficial da União; 2014.
• ¹³ Brasil. Lei nº 13.958, de 18 de dezembro de 2019. Cria a Agência para o Desenvolvimento da Atenção Primária à Saúde - ADAPS, e dá outras providências. Diário Oficial da União; 2019.
• ¹⁴ Brasil. Medida Provisória nº 1.165, de 2023. Dispõe sobre o Programa Mais Médicos e outras providências. Diário Oficial da União; 2023.
• ¹⁵ Brasil. Medida Provisória nº 1.165, de 10 de janeiro de 2023. Dispõe sobre a criação do Programa Mais Médicos e dá outras providências. Diário Oficial da União; 2023.
• ¹⁶ Brasil. Ministério da Saúde (MS). Programa Médicos pelo Brasil [Internet]. Brasília: MS; 2019 [acessado 25 out 2024]. Disponível em: https://www.gov.br/saude/pt-br/assuntos/noticias/ministerio-da-saude-lanca-o-programa-medicos-pelo-brasil.
• ¹⁷ Soranz D, Pinto LF, Penna GO. Eixos e a Reforma dos Cuidados em Atenção Primária em Saúde (RCAPS) na cidade do Rio de Janeiro, Brasil. Cien Saude Colet 2016; 21(5):1327-1338.
• ¹⁸ Barbosa ACQ, Silva Junior AG, Turci MA, Mendes PS. Eficiência e Gestão Pública em Saúde na APS. APS Rev 2021; 3(2):144-153.
• ¹⁹ Barcelos COG, Andrade MV, Botega LA, Malik AM. Censo das organizações sociais de saúde brasileiras: levantamento e caracterização. J Bras Econ Saude 2022; 14(Supl. 1):15-30.
• ²⁰ Brasil. Ministério da Saúde (MS). Portaria nº 2.488, de 24 de outubro de 2011. Aprova a Política Nacional de Atenção Básica. Diário Oficial da União; 2011.
• ²¹ Howe A, Anderson MIP, Ribeiro JM, Pinto LF. Reforma da Atenção Primária à Saúde no Rio de Janeiro: comemorando os 450 anos de fundação da cidade. Cien Saude Colet 2016; 21(5):1324-1326.
• ²² O'Dwyer G, Graever L, Britto FA, Menezes T, Konder MT. A crise financeira e a saúde: o caso do município do Rio de Janeiro, Brasil. Cien Saude Colet 2019; 24(12):4555-4568.
• ²³ Rio de Janeiro. Prefeitura do Rio de Janeiro (PCRJ). Plano Estratégico Rio Futuro: Plano estratégico 2021-2024. Rio de Janeiro: PCRJ; 2021.
• ²⁴ Rio de Janeiro. Prefeitura do Rio de Janeiro. Subsecretaria de Promoção, Atenção Primária e Vigilância em Saúde. Contrato de Gestão nº 08 de 2022. Diário Oficial 2022; 3 maio.
• ²⁵ Rio de Janeiro. Prefeitura do Rio de Janeiro. Secretaria Municipal de Saúde do Rio de Janeiro. Subsecretaria de Promoção. Atenção Primária e Vigilância em Saúde. Instrutivos dos termos de colaboração [Internet]. 2022 [acessado 2024 out 23]. Disponível em: https://saude.prefeitura.rio/ctgos/instrutivos-dos-termos-de-colaboracao/subpav/.
  » https://saude.prefeitura.rio/ctgos/instrutivos-dos-termos-de-colaboracao/subpav
• ²⁶ Rio de Janeiro. Prefeitura do Rio de Janeiro. Secretaria Municipal de Saúde do Rio de Janeiro. Contratos de Gestão, Convênios e Demais Parcerias Voluntárias. Hospitais [acessado 2024 out 25]. Disponível em: https://saude.prefeitura.rio/ctgos/9621-2/.
  » https://saude.prefeitura.rio/ctgos/9621-2
• ²⁷ Rio de Janeiro. Secretaria Municipal de Saúde do município do Rio de Janeiro. Subsecretaria Geral. Portal da Transparência SISREG [Internet]. 2024 [acessado 2024 out 15]. Disponível em: https://web2.smsrio.org/minhasaudeRio/#/.
  » https://web2.smsrio.org/minhasaudeRio
• ²⁸ Rio de Janeiro. Secretaria Municipal de Saúde do Rio de Janeiro. Contrato de Concessão Administrativa nº 197/2023 - Parceria Público-Privada Souza Aguiar [Internet]. 2023 [acessado 2024 out 25]. Disponível em: https://www.ccpar.rio/mapa/complexo-hospitalar-souza-aguiar/.
  » https://www.ccpar.rio/mapa/complexo-hospitalar-souza-aguiar
• ²⁹ Conselho Nacional de Secretários de Saúde (CONASS). Nota técnica nº 40/2012: Gerência de unidades públicas de saúde - Organização Social, Fundação Estatal e Parceria Público Privado. Brasília: CONASS; 2012.
• ³⁰ Saloti MHS, Medeiros LK, Oening AB, Marcon CEM. Organizações Sociais na atenção básica em saúde nas capitais da Região Sudeste do Brasil: uma análise crítica. Cad Saude Publica 2019; 35(9):e00103319.
• ³¹ Correia MVC, Santos VM. Privatização da saúde via novos modelos de gestão: Organizações Sociais (OSS) em questão. In: Bravo MIS, Andreazzi MFS, Menezes JSB, Lima JB, Souza RO, organizadoras. A mercantilização da saúde em debate: as Organizações Sociais no Rio de Janeiro. Rio de Janeiro: Rede Sirius; 2015. p. 33-41.
• ³² Silva VLC, Turci SRB, Oliveira APN, Richter AP. O risco de parcerias público-privadas em saúde pública pode ser classificado? Cad Saude Publica 2017; 33:e00086316.
• ³³ Cegatti F, Carnut L, Mendes Áquilas. Terceirizações na área da saúde no Brasil: reflexos no SUS, nas políticas sociais e nos trabalhadores. J Manag Prim Health Care 2020; 12:1-41.
• ³⁴ Portal das OS. O Observatório Nacional das Organizações Sociais [Internet]. 2024 [acessado 2024 out 25]. Disponível em: https://www.portaldasos.com.br/.
  » https://www.portaldasos.com.br
• ³⁵ Costa NR, Silva IM, Lima PT, Silva TS, Costa ICM, Figueiredo IVO. A implantação em larga escala da Estratégia de Saúde da Família na cidade do Rio de Janeiro, Brasil: evidências e desafios. Cien Saude Colet 2021; 26(6):2075-2082.
• ³⁶ Giovanella L, Mendonça MHM, Fausto MCR, Almeida PF, Bousquat A, Lima JG, Seidl H, Franco CM, Fusaro ER, Almeida SZF. A provisão emergencial de médicos pelo Programa Mais Médicos e a qualidade da estrutura das unidades básicas de saúde. Cien Saude Colet 2016; 21(9):2697-2708.
• ³⁷ Ramos AVM, Oliveira ML, Messias IMO, Fernandes FECV, Carreiro MAG, Nascimento MF, Santos JG, Santo LCN, Carvalho IJSA. Demanda reprimida de cirurgias eletivas em tempos de pandemia. OLEL 2024; 22(6):e5223.
• ³⁸ Buus MO. Modelo de sistema de conhecimento para gestão de listas de espera para cirurgias no Sistema Único de Saúde [tese]. Florianópolis: Universidade Federal de Santa Catarina; 2015.
• ³⁹ Organisation for Economic Co-operation and Development (OECD). Waiting Times for Health Services: Next in Line [Internet]. 2020 [cited 2024 out 25]. Available from: https://doi.org/10.1787/242e3c8c-en
  » https://doi.org/10.1787/242e3c8c-en
• ⁴⁰ Silva VLC, Turci SRB, Oliveira APN, Richter AP. O risco de parcerias público-privadas em saúde pública pode ser classificado? Cad Saude Publica 2017; 33:e00086316.
• ⁴¹ Andrade LRP, Pinto ICM. Parceria público-privada na gestão hospitalar no Sistema Único de Saúde da Bahia, Brasil. Cad Saude Publica 2022; 38(2):e00018621.
• ⁴² Kingdon JW. Agendas, Alternatives, and Public Policies. 2ª ed. Harlow: Pearson Education Limited; 2014.
• ⁴³ Oliver TR. The politics of public health policy. San Francisco: Jossey-Bass; 2006.
• ⁴⁴ Brasil. Ministério da Saúde (MS). E-Gestor AB: ferramenta de gestão da Atenção Básica [Internet]. [acessado 2025 jan 31]. Disponível em: https://egestorab.saude.gov.br/.
  » https://egestorab.saude.gov.br
• ⁴⁵ Brasil. Ministério da Saúde (MS). Cadastro Nacional de Estabelecimentos de Saúde - CNES [Internet]. [acessado 2025 jan 31]. Disponível em: http://cnes.datasus.gov.br
  » http://cnes.datasus.gov.br
• ⁴⁶ Brasil. Ministério da Saúde (MS). Sistema de Informações Hospitalares do SUS (SIH/SUS) [Internet]. [acessado 2025 jan 31]. Disponível em: http://sihd.datasus.gov.br/.
  » http://sihd.datasus.gov.br
• ⁴⁷ Rio de Janeiro. Prefeitura do Rio de Janeiro. Secretaria Municipal de Saúde. Portal de Transparência SISREG [Internet]. [acessado 2025 jan 31]. Disponível em: https://web2.smsrio.org/minhasaudeRio/.
  » https://web2.smsrio.org/minhasaudeRio
• ⁴⁸ Rio de Janeiro. Prefeitura do Rio de Janeiro. Portal da Transparência da Prefeitura do Rio de Janeiro [Internet]. [acessado 2025 jan 31]. Disponível em: https://transparencia.prefeitura.rio/.
  » https://transparencia.prefeitura.rio
• ⁴⁹ Brasil. Ministério da Saúde (MS). Secretaria de Atenção Primária à Saúde. Departamento de Saúde da Família. Coordenação-Geral de Estratégia da Saúde da Família. Nota Técnica nº 301/2022-CGESF/DESF/SAPS/MS. Nota Metodológica da Cobertura Potencial da Atenção Primária à Saúde no SUS. Brasília: MS; 2022.

• Chief editors:
  Maria Cecília de Souza Minayo, Romeu Gomes, Antônio Augusto Moura da Silva

Publication Dates

• Publication in this collection
  11 Aug 2025
• Date of issue
  July 2025

History

• Received
  25 Oct 2024
• Accepted
  10 Feb 2025
• Published
  12 Feb 2025