Health services management modalities in the Brazilian Unified National Health System : a narrative review of research production in Public Health ( 2005-2016 )

The current study aimed to systematically analyze trends and priorities in the theoretical and conceptual approaches and empirical studies on specific health services management modalities in the Brazilian Unified National Health System. A narrative review of the literature identified, in 33 publications, the location and nature of services, management models, methodological procedures, and study outcomes. The research deals mainly with the models’ conceptual and legal characteristics and management practices, in addition to addressing contracts, procurement, human resources, financing, and control mechanisms. In conclusion, the literature is limited and concentrated in the State of São Paulo, showing little theoretical diversity and methodological weaknesses, while it is nonconclusive as to the superiority of one management model over another. New evaluation studies are needed that are capable of comparing different models and assessing their performance and their effects on the quality of health services’ provision, the population’s health, and the health system’s organization. Health Management; Health Services Administration; Unified Health System This article is published in Open Access under the Creative Commons Attribution license, which allows use, distribution, and reproduction in any medium, without restrictions, as long as the original work is correctly cited.


Introduction
The states and municipalities that comprise the Brazilian Unified National Health System (SUS) can manage, maintain, and provide health services directly or indirectly, including through complementary participation by the private sector, in order to meet their Constitutional duty to ensure healthcare for the entire population 1 .
Healthcare establishments that serve users of the SUS have diverse organizational compositions, administrative formats, and management models, changing over time due to administrative reforms, legal interpretations, political decisions, and complementary federal, state, and municipal legislations.
In addition to health services provided under direct federal, state, and municipal administration, the public sector delegates or transfers the execution of services under the SUS to indirect administration, which can come under various legal formats, including autarquias (independent agencies), foundations, government-owned companies, and semi-public corporations.For the same purpose of providing healthcare services, public administrators can opt for complementary private administration, signing contracts or agreements with social organizations, nonprofit civil society associations, private foundations, and private companies 2 .
Research on health services management in Brazil 3 has endeavored to orient the management of hospitals and public healthcare units, administrators' practices, the nature and oversight of agreements, work processes, and users' perceptions, especially through reports, essays, case studies, and evaluative studies.As for the health system's management, studies thus far have examined participatory management, financing, regulation, and evaluation of services 4 .
However, there is an important gap related to the characteristics, functioning, and efficacy of the arrangements and models within the public healthcare system.
The current review focuses on the research production in Public Health, in the subarea Health Policy, Planning, and Management, aimed to summarize trends and priorities in the theoretical and conceptual approaches and the empirical studies on specific health services management modalities in the SUS.
The aim is to contribute to the understanding of the current challenges for improving the health services' management by adding evidence from studies on the dimensions that characterize, compare, or differentiate the models featured in the literature.

Methodology
A narrative literature review was performed, seeking to summarize the research production on this theme (since the topic was not specific enough to address with a systematic review) 5 .
We reviewed Brazil's domestic research in the field of Public Health on health services management modalities in the SUS.In order to increase its reproducibility and transparency, the review used explicit methods and informed the electronic databases with the terms used in the search strategy, screening strategy, eligibility criteria, data extraction, and summary approach.
The literature search was conducted by a reviewer (A.F.R.) from May 1 to 29, 2017, and included MEDLINE (via PubMed), EMBASE, Latin American and Caribbean Health Sciences Literature (LILACS), Scientific Electronic Library Online (SciELO), and Google Scholar and covered studies published from January 2005 to December 2016.Additional relevant studies were identified in other sources, based on the reference lists from the studies obtained in the electronic search.
The start of the study period was set as the date of approval of the legal framework for one of the possible management modalities, Public-Private Partnerships (PPPs), regulated by Law n. 11,079/2004 6 .The period was thus intended to cover research production on the main alternative management models existing in Brazil at the time.
The search strategies used specific indexing terms (Medical Subject Headings -MeSH; and Descritores em Ciências da Saúde -DeCS).For MEDLINE and EMBASE, the following terms were included: "State Reform", "Reform of State", "Models of Health Sector Reform", "Health Sector Reform", "Organizational Models", "Health Organizations", and "Public-Private Partnerships".The search also used the filter for date of publication from 2005 and 2016 and limited to "Brazil".
For Google Scholar, we used the specific search system for this database.A manual search was also done in the references from the articles selected in the previous databases.Publications were obtained with the following terms (in Portuguese): "Administração Direta", "Organização Social", "Fundação Estatal", "Fundação Pública", "Parceria Público Privada", "PPPs", "Empresa Brasileira de Serviços Hospitalares".Free terms were included to increase the search strategy's sensitivity and identify book chapters, in addition to scientific articles.
Two independent reviewers (A.F.R., P.C.D.S.) first read the publications' titles and abstracts, and then read the full texts in the second stage.Eligibility criteria for analysis of research production were scientific articles, books, book chapters, theses/dissertations, and reports that presented, described, or discussed the characteristics of at least one health services management model or format in the SUS.
The search first eliminated the publications that did not deal with health-related topics.Then it excluded the publications that dealt with the health system, but on topics unrelated to health services management modalities, such as decentralization, planning, clinical protocols, user satisfaction and participation, human resources, and work processes.Articles on supplementary (private) healthcare services or management of health plans and insurance were not included.
Two independent reviewers (A.F.R., P.C.D.S.) extracted the data (object location, management model, outcomes, study design, data source, type of analysis, number of participants) from the selected publications.In case of disagreement, the decision was made by a third reviewer (M.C.S.), and the publications were then grouped and categorized.

Results
A total of 341 records were identified on the theme, and after exclusion of duplicates, 308 records were screened.At the end of the full reading of 59 publications, 33 were included in the analysis (Figure 1).
Of the 33 selected studies, 18 publications (54%; 16/33) analyzed the management of services located in the State of São Paulo linked to the State Health Secretariat (SES) or some Municipal Health Secretariat.There were two studies (6%; 2/33) on equipment management in the State of Mato Grosso and one (3%; 1/33) that analyzed the PPP model in the following places: Bahia, Ceará, Federal District, Espírito Santo, Mato Grosso, Rio de Janeiro, Roraima, São Paulo, Belo Horizonte (Minas Gerais), Manaus (Amazonas), city of São Paulo, and Sorocaba (São Paulo).
The health services covered in the studies in the literature included public units and hospitals managed by State and Municipal Health Secretariats, besides private and university hospitals.Thirteen articles (39%; 13/33) reported exclusively on hospitals; two articles (6%; 2/33) analyzed hospitals and other health units; one article (3%; 1/33) analyzed a non-hospital health unit.One of the studies (3%; 1/33), with a nationwide scope, addressed both public and private healthcare establishment in general.The other publications (48%; 16/33) did not deal with specific types of health services.
As for the studies' outcomes, four themes stood out among others in the literature: human resources, contracts and purchases (procurement), control or oversight mechanisms, and financing.

Figure 1
Flowchart of study selection in the review.

Table 1
Selected publications according to management models, location, types of health services/institutions, and outcomes.

Discussion
Part of the literature analyzed here is seeking an explanation for the causes, emergence, and dissemination of alternative management models for public healthcare services.The authors adopted different approaches, including neoliberal premises, state reform, and the presentation of private administrative tools as factors for better or worse health services performance.The management models were presented alternatingly as the modernization or the elimination of the state's role and responsibilities in health.The first explanation, exogenous and macropolitical, is situated in the scenario of privatizations 7 and transfer of the government's responsibilities to the private sector, with a gradual retreat from public policies and dismantlement of the state apparatus 8 .But the explanation also refers to the management reform scenario, which provided for transferring the supply of public services to social organizations and non-state public providers, which would receive state funding, with their action governed by management contracts.Other objectives included the existence of regulatory agencies, results-based management, and merit-based incentives, under the argument of making public administration more efficient, rationalizing expenditures, and offering citizens services with better quality, assigning greater importance to financial results and the production of services 9,10 .
The second explanation, endogenous to management, was a response to the difficulties encountered by direct government administration in adequately managing health services, due to its low operational capacity, lack of budget financial, and administrative autonomy, low quality control, external political interference, and excessive bureaucracy for hiring staff, making adjustments, and purchasing inputs, medicines, and equipment.Added to the above were the typical rules and procedures of direct government administration and Brazil's Fiscal Responsibility Law, which limits workforce expansion and qualification 11,12,13 .
The literature reviewed here also addressed the differences between management modalities, based on empirical data produced in the studies and considering the legal configurations and frameworks.
Direct public administration follows the rules governing public service in Brazil, e.g., Art.37 of the 1988 Federal Constitution and Federal Law n. 8,666 of June 21, 1993 14 .Meanwhile, the so-called Social Organizations, structural entities of the 1995 state administrative reform 10 , were regulated by Federal Law n. 9,637 of May 15, 1998 15 and state and municipal legislations, and reconfirmed by the Federal Supreme Court in 2015 16 .PPPs, governed by private law, were established under Federal Law n. 11,079 of December 30, 2004 6 .Although there is no specific legislation, there are bills under review 17 in the Brazilian Congress to regulate the Government Foundations as entities of indirect public administration, providing them with greater flexibility and autonomy than the current autarquias and public foundations.The Government Foundations were proposed under Complementary Bill of Law n. 92/2007, which regulates Art.37, item XIX, of the 1988 Federal Constitution 11,12 .
Cad. Saúde Pública 2018; 34(4):e00114217   The public procurement process is one of the principal elements in the rules governing Public Administration, establishing a series of duties and procedures for signing a contract or making a purchase.For Direct Administration, Law n. 8,666/1993 applies in full, leaving less flexibility 18 .Government Foundations, as entities of Indirect Administration, allow more streamlined procedures due to their own specific regulations for public bidding (although still ruled by Law n. 8,666/1993 11 ).Meanwhile, the OSS enjoy some flexibility since they are not subject to government procurement rules; their obligations are set in the form of management contracts 12,19 .Finally, the purchases made by PPPs are not subject to the restrictions imposed on the other management modalities 20,21 .
The formats for hiring and paying human resources, plus the meritocracy and results-based policies, were addressed by various studies in the current review of management models.In Direct Administration, staff hiring must comply with Art.37 of the 1988 Federal Constitution, which requires public admissions exams and job stability, with the exception of positions subject to free nomination and dismissal, a situation that sometimes generates difficulties in updating the workforce 22,23 .However, this requirement does not exist in the other models.With some differences, the models allow hiring staff according to Brazil's Consolidated Labor Laws (CLT) 18,19,24,25,26 .In addition to the flexibilization, there is a positive result in human resources management under OSS when compared to Direct Administration in cases where a change in organizational culture has been identified, with greater employee participation and accountability 27 .
As for financing of services, the Foundations are paid as a function of production, with payment usually tied to pre-agreed targets 12,28 .Pay for performance is also a tool used to finance OSS, through management contracts 19,29 .PPPs are also financed according to rules and criteria set during the bidding process 20,30 .
Regardless of the management model, formal internal and external control mechanisms are provided for, such as supervision by the Brazilian Ministry of Health, oversight and evaluation by the Federal, State, and Municipal Accounts Courts and Offices of the Public Prosecutors, subordination to social control by the community-based Health Councils, and duties as to publicity of decisions, expenditures, and contracts 12 .The OSS and PPPs are limited by management contracts and performance measurement.As long as there is agreement on targets, instruments for follow-up, objective criteria to assess production, and budgetary limits, theoretically it is possible to evaluate and demand better performance from the Social Organizations 19 .Meanwhile, the PPPs are presented as having a unique oversight model, through the "establishment of output-based performance indicators, that is, based on targets and results (...) measured a posteriori" 20 (p.163).Payment for the services provided only occurs after ensuring the scope of what was stipulated in the contract.
Despite the formal oversight and performance assessment mechanisms, the literature points to flaws in the delegation of public health services to management not conducted by Direct Administration.In the case of OSS, the rhetoric of the benefits of managerialism may fail to weigh the private interests involved in healthcare management 31 .Concerning the PPPs, based on a descriptive and Cad.Saúde Pública 2018; 34(4):e00114217 conceptual discussion 32 and interaction with relevant actors in this model's implementation 33 , the literature indicated the private sector's capacity to influence and enable projects in which it has a vested interest, with a view towards obtaining profits.
Even when dealing with real-life cases, the research focused predominantly on the model's conceptual perspective, normative framework, underlying legislation, management practices, and contractual relations.
A few studies also criticized the OSS' lack of accounting transparency 34 , besides exposing the private interests involved in the services' management 31 and questioning the alleged expansion of the population's access to the services provided by these models 35 .
There was no consensus among the few comparative studies as to the superiority of one model over another.Public hospitals managed by OSS showed higher economic efficiency and human resources management when compared to Direct Administration 12,19 , in addition to lower expenditure per hospital bed 36 .Still, services administered by OSS in São Paulo performed similarly to services under Direct Administration in Curitiba (Paraná) 21 .As for staff performance, due to greater flexibility in hiring and wage procedures 18 , the workforce under OSS were more highly qualified, according to one study 27 .Meanwhile, another study found no difference between OSS and Direct Administration in terms of human resources management 21 .PPPs and Government Foundations were not even compared to other models, perhaps because they are still not as common in Brazil.
Studies with comparisons of models were not only few in number, but methodologically limited.Only one study conducted economic assessments comparing two or more alternative models, simultaneously evaluating costs and results 36 .No quality assessments or comparative analyses were done on health services management under different models, considering characteristics such as accessibility, equity, satisfaction, or efficiency.
Neither were there any studies on possible impasses with the coexistence of different models in the same healthcare network or the repercussions from the coexistence of heterogeneous management models on staff, services, and pay, which can impact the organization and functioning of the health system as a whole or even hinder the configuration of an integrated network of services linked at increasingly complex levels in order to guarantee comprehensive healthcare in each given region.
The review also failed to identify any systematic or narrative literature review or the use of surveys with managers, users, and health professionals, just to mention two examples of methodological procedures that could have been employed to analyze a given model in greater depth or to compare one modality to another.
The review showed a heavy concentration of studies in the State of São Paulo, with 18 publications (55%; 18/33).According to the Brazilian Survey of Medical-Sanitary Assistance (Brazilian Institute of Geography and Statistics.http://www.ibge.gov.br/home/estatistica/populacao/condicaodevida/ams/2009/, accessed on 18/Jun/2017), in 2009, of the 94,070 public and private, for-profit and nonprofit, outpatient and inpatient healthcare establishments in Brazil, 15% (14,215) were located in the State of São Paulo.Considering the nationwide presence of alternative (non-Direct Administration) health services management modalities, the concentration of studies in São Paulo does not reflect the establishments' national distribution and fails explore the models' diversity of characteristics and outcomes.
With a predominance of qualitative studies, the review showed that most of the selected studies provided weak descriptions of their methodologies, and that some descriptive and content analyses failed to produce conclusions or even interpretative inferences.The theoretical and methodological references used in the articles were limited, corroborating a previous study by Deslandes & Iriart 37 .The latter authors analyzed the repertoire of methodologies in scientific production on social and human sciences in health and concluded, "there is a monotony and predominance of few analytical modalities and data production techniques, narrowing what would otherwise be a wide range of choices and innovative research approaches" 37

(p. 2385).
As with non-Brazilian reviews 38,39 , the current review provided little evidence of the real impact of alternative models or public-private arrangements on health services management.It has not been proven that one model is intrinsically more efficient than (or superior to) another, although isolated case studies attribute the results of given services or those in specific contexts to the management modality.
Cad. Saúde Pública 2018; 34(4):e00114217 The comparative analyses of the healthcare management models' efficiency or quality characteristics (public, private, for-profit, non-profit, mixed) concluded that the differences are scarcely significant or nonconclusive 18,21,36 .Efficiency in services provision, whatever the management model, will depend on the health system's characteristics and factors such as financing, regulation, external social control, degree of public monitoring of the execution of outsourced or hired services, competition, institutional development, and staff hiring and payment policies.

Conclusion
In conclusion, the Brazilian literature on health services management models in the SUS has produced few articles, geographically concentrated, mainly in the State of São Paulo, with only a handful of studies on the more recently introduced or less widespread modalities.This limited research production is marked by a narrow diversity of theories and weak methodological approaches, emphasizing the legal frameworks and configurations and focusing on the hiring, contractual, procurement, human resources, financing, and control processes.
The review points to the need for more in-depth research in keeping with the system's complexity and scope, considering that alternative (non-Direct Administration) management models are now hegemonic in most of Brazil's municipal and state public healthcare networks.
The approaches that call for more studies would include the shareholding formats, the experience with the expansion of coverage and capital accumulation by the organizations, entities, and companies working with services management in the SUS, as well as networks of influence and the mechanisms used by them to defend their vested interests vis-à-vis government policymakers.
The current study also suggests the importance of adopting other methodological approaches in the literature on the issue, in order to produce evaluative studies capable of comparing different models and drawing on research procedures, methods, and instruments by which the management modality can be judged for its performance and its effects on quality of care, the population's health, and organization of the health system.

Resumen
El presente estudio tuvo como objetivo analizar sistemáticamente las tendencias y prioridades en los enfoques teóricos y conceptuales y estudios empíricos sobre modalidades específicas de gestión de los servicios de salud en el Sistema Único de Salud de Brasil.Una revisión narrativa de la literatura identificó, en 33 publicaciones, la ubicación y la naturaleza de los servicios, los modelos de gestión, los procedimientos metodológicos y los resultados del estudio.La investigación se ocupa principalmente de las características conceptuales y legales y las prácticas de gestión de los modelos, además de abordar los contratos, las adquisiciones, los recursos humanos, el financiamiento y los mecanismos de control.En conclusión, la literatura es limitada y concentrada en el Estado de São Paulo, mostrando poca diversidad teórica y debilidades metodológicas, mientras que no es concluyente en cuanto a la superioridad de un modelo de gestión sobre otro.Se necesitan nuevos estudios de evaluación que sean capaces de comparar diferentes modelos y evaluar su desempeño y sus efectos sobre la calidad de la provisión de servicios de salud, la salud de la población y la organización del sistema de salud.

Table 1 (continued)
Foundation for the Support of Teaching, Research, and Healthcare, of the HCFMRP, University of São Paulo; HCFMrP: Teaching Hospital, ribeirão Preto School of Medicine; HiAe: Albert eisntein israeli Hospital; NA: not applicable; Ni: not informed; SUS: Brazilian Unified National Health System; UBS: primary healthcare unit.

Table 2
Selected publications according to methodological procedures.

Table 2 (continued)
Brazilian Survey of Medical-Sanitary Assistance; CGCSS: Coordination of Services and Contracts Management of the São Paulo State Health Salud; Administración de los Servicios de Salud; Sistema Único de Salud Submitted on 04/Jul/2017 Final version resubmitted on 12/Jan/2018 Approved on 26/Jan/2018