Distributive conflict: analysis of the Program for Improving Access and Quality of Primary Care (PMAQ-AB) in two Brazilian northeastern capitals

This article analyzes the implementation of the Program for Improving Access and Quality of Primary Care (PMAQ-AB) in the context of a national political scenario of deep transformations, from the weak reformism that promoted slow extension of rights to the strong counter-reformism of neoliberal restoration. It is a case study with health workers, managers, and counselors in two capital cities in northeastern Brazil, discussing matters of work and distributive disputes of public resources. Results show the intensification of these conflicts in health and the unfavorable outcome for workers after the parliamentary coup in 2016 political context. Local dynamics expose the wage contraction and individualization of labor relations and the reassertion of meritocracy as an ideological ground for precariousness. Workers oppose this, reaffirming their collective class condition, favoring the benefit derived from PMAQ for fully regaining their group wages.


Introduction
Beginning with the irruption of the 2008 international financial crisis, and albeit in heterogeneous ways, countries in the global South and North have experienced deep political, social and economic crises, accompanied by increasing social inequalities and fiscal austerity measures, privatization of state assets, and the rise of authoritarian policies, even in regimes considered consolidated democracies [1][2][3] .This period was one of profound political and economic change in Brazil, defined by Singer 4 as a transition from "weak reformism" during governments led by the Workers' Party to that of "strong counter-reformism" post 2016.
The concept "weak reformism" is defined as a slow and contradictory process of rights extension and social incorporation of broad popular sectors, through the adoption of democratizing economic and social policies, in a favorable external economic environment 5 .Former president Lula (2003-2010) perceived "a window of opportunity for weak reformism, thanks to the commodities boom, and effectively took advantage of this gap" by implementing policies such as increasing the actual value of the minimum wage, job creation, "the extension of the Continuous Cash Benefit (BPC), the University for All Program (Prouni), Housing program 'Minha Casa Minha Vida' (MCMV)", among others 5 (p.12).This was possible by a certain way of conducting the government known as Lulism, a "model of arbitrage between the key classes", in which former president Lula sought to promote a balance between the interests of various class fractions, so that none of them would have "the strength to impose its own wishes" 6 (p.144).
The increase in the participation of salaries in the composition of the Gross Added Value of the Brazilian economy was another consequence of the policies adopted, and would have produced an "undesired revolution" in the Brazilian labor market 7,8 , with the "tendency of real salaries to grow continuously above productivity growth, which progressively worsened the distributive conflict and reduced profit margins and rates for companies" 9 (p.176).Distributive conflict is established when there is a mismatch between profit expectations and average wages between employers and workers.
It should be noted, however, that despite such intensification and the significant reduction in poverty and extreme poverty, Carvalho 10 points out that there was no proportional reduction in inequality, with growth in capital income concentrated in the richest fractions of the population 10 .
As of 2014, this landscape changes with a strongly restrictive fiscal policy, austerity measures, and contraction of effective demand 9 .The cycle of rights expansion and public services supply was countered by a macroeconomic policy of neoliberal restoration, with the dismantling of public policies and revision of the social pact consolidated in the Constitution of 1988 4 .This process was intensified with the "parliamentary coup" of 2016 4,[11][12][13] , initiating the phase of "strong counter-reformism" 4,14-16 : a set of reforms initiated in the Temer government, further deepened in the Jair Bolsonaro government, which oppose the gradual and structural changes achieved in the Lulist cycle.Examples are the Constitutional Amendment 95 (EC-95), which establishes a ceiling for public spending (except for the payment of interests on the public debt), with contraction of public spending, which impacted social policies and the State's investment capacity; the labor reform of 2017, and the pension reform.
Regarding the health sector, this conjuncture favors the passage from the historical public underfunding of the system -and the struggle to overcome it by adopting a national floor of public investment in the sector (2000 -2015), to the period of de-funding imposed by the EC 95 [17][18][19][20] , with dismantling of public policies, producing an increase in preventable child hospitalizations and mortality 21,22 .
Gomes and Merhy 23 point out that budget cuts are added to the change in the National Primary Care Policy in 2017, the expansion of outsourcing, privatization, and the focalization of service provision, with a breach of the principles of universality, equity, and gratuity that guide the Brazilian National Health System (SUS).These transformations directly affect the management of health labor force and the salary policies linked to distributive conflicts over public funds.
It is in this troubled context that the Program for Improvement of Access and Quality of Primary Care (PMAQ-AB) was designed and executed.Running from 2011 to 2019, its goal was to expand access to primary health care services and establish a national quality standard, based on comparable parameters, with permanent monitoring and evaluation 24 .
The PMAQ-AB was implemented through a process of negotiation and pacts among the three spheres (federal, state, and municipal) of SUS management, by commitment contracts and indicators among management, workers, and users; of program implementation; of access and quality assessment; and of re-negotiation [24][25][26][27] .The program went through three cycles (cycle 1: 2011-2012, cycle 2: 2013-2015, and cycle 3: 2015-2019) 28 , with variations in the agreement processes.Its implementation was permeated by "constitutive tensions" related to chronic underfunding of health care; local negotiation of work processes and resource use patterns; permanent education policy; external evaluation dynamics; and the reaffirmation of primary care as the coordinator of care and organizer of care networks 26 .
Gomes and Merhy 26 pointed out the limits and possibilities of PMAQ-AB in the effective materialization of the right to health: on the one hand, the program expanded funding and support to improve services in municipalities where there were already consistent local projects and good governance capacity; and on the other, it favored institutional coercion on workers and managers, especially in places with an authoritarian management culture.
In light of this debate, this article proposes to understand the implementation processes of the PMAQ-AB in two capitals of the Brazilian Northeast, as analyzers of this scenario of transformations in the country.To this end, we seek to answer the following questions: What reflections can be found between the effectiveness of public health policy at the local level and the national political, economic and social context?How did a national program created to expand health financing and the quality of services materialize in the local work conditions, in relation to the distribution of public resources?

Method
This study is a qualitative analysis, case-study type, in an empirical investigation of a contemporary phenomenon, the implementation of the PMAQ-AB, in its real context, space-time, in which boundaries between phenomenon and context are not clear; of a flexible nature, relying on more than one source of evidence: interviews and focus groups 29 .It was carried out in two state capitals in the northeastern part of Brazil.We tried to highlight in this study those elements related to the work and the disputes over the distribution of public resources.
The intentional sample of the research was formed by two representatives of the municipal health management, two health counselors, and four focus groups with workers from family health teams (with an average of six participants each), totaling 30 participants.
The interview and focus group techniques were chosen for allowing the expression of worldviews related to the social, economic, and political insertion in the studied scenario 29 .Both were conducted between 2019 and 2020, at the research participants' workplaces by four interviewers (two in each state), previously trained.They were facilitated by guiding questions about the implementation of PMAQ-AB, its effects and limitations.All were voice-recorded and transcribed in full.The field diary was used by the interviewers to record the impressions perceived during the collection.
To preserve the participants' anonymity, the cities were called Capital 1 and Capital 2, and the participants were identified as: G for manager, C for counselor, and GF for focus groups, with the addition of the numbering of the respective city.
In order to understand the varied dimensions of the observed phenomena, the analysis considered the different levels of integration of the research participants: 1. the "microsocial processes", such as the local organization for implementation of the PMAQ-AB, "the participants, institutionality, forms of organization, explicit or underlying political projects" of individuals who interact in the production of a local reality; 2. the "meso-social" processes, which refer to the forms of collective action of the individuals in focus, their social and institutional interactions that go beyond the local dimension, besides the participation in public and dispute spaces for the implementation of the public policy; and 3. the "macro-social" processes, related to spaces of broader scope and the historical context in which the social interactions are inserted 30 (p. 33).To analyze these different levels of political-social integration, we mobilized analytical categories of different degrees of abstraction: those to which the research participants themselves resort to interpret their actions and lived contexts; intermediate concepts that allow to tread an analytical path from the lived reality to the theoretical abstraction exposed in the political definition of the current moment; and general concepts that define the historical context in which the observed interactions are inserted.
The empirical material allowed the analytical elaboration around a central category: distributive conflict.This is understood as the political and economic struggles for the distribution of goods resulting from labor, both in disputes over public funds (social distribution of resources collected by the State, involving taxation, tax waivers and targeting of government spending, for example), and in the direct relationship between capital and labor in the composition of the country's Gross Added Value 7,9,31 .
The study was approved by the Research Ethics Committee (CAAE 90331418.6.0000.8069,Opinion #: 2.960.514), and all respondents signed the Informed Consent Form.

Results and discussion
The analysis of the local implementation of PMAQ-AB identified an intensification of distributive conflicts experienced in primary care, related to the conjunctural shifts in the country during the program.The focus groups and interviews made this process explicit through two combined axes: the reference to the decrease (in the amount and frequency) of resources transferred by the program in a context of wage stagnation; and the individualization of evaluation and remuneration as a counterpoint to the collective dimension of work.In contrast, there was the workers' expectation that the PMAQ-AB remuneration would mitigate the effects of salary losses, combined with the struggle in defense of the collective conception of health work.These are local and sectorial expressions of the transformations in the labor market and of the intensification of disputes over the public budget in a context of crisis.
The understanding by workers and management that the PMAQ-AB resources are salary supplementation, and not payment for performance, imposes limits to the achievement of the program's objectives."Owing to the fact that it is an extra income, in financial terms, we count on this amount to do something different, which we can't do with our salaries" (FG1.1), says a participant, pointing out that, in the last eight years, the mayor "never gave us a raise".Other team participants agree: We never had a raise, you know?So, when this money comes, it's a total joy.(G.1.1)Even when we [community health agents] got the national wage floor, what we had outside, he [the mayor] took away.So, PMAQ is a relief for us, the month we receive PMAQ is the month we can breathe.(G.1.1) The program, planned as an incentive/bonus linked to performance, is now disputed by the workers for salary composition.
In fact, the resource provides a way to give more value to that professional.We don't have that policy of public servants having a readjustment.So, what did the worker see?He saw that by improving his service, he would get a higher grade, consequently a higher resource [...].So, it provides a better quality of life for him and his family and consequently a better service is delivered to the population.(C1) In addition to breaking off the links between remuneration and performance due to the context of worsening working conditions, there was the perception of a decrease in the amounts transferred.Due to the evaluation of the teams throughout the cycles, the Program foresees variations in the incentive values, which occur due to local aspects, such as changes in the periodicity or amount directed to the workers, and the inclusion of other categories to be remunerated, among others.It is worth pointing out that the maintenance of fixed nominal values in periods of inflationary acceleration produces a perception of reduced purchasing power.Thus, for different reasons, the worker effectively began receiving lower values or perceiving that the resource was less relevant.This produced an understanding of worsening compensation values and a disincentive in a program originally implemented to motivate the work process and the improvement of service quality.
We had reductions between the first cycle and the third cycle, we had a decrease in values [...].Especially from the second to the third cycle there was reduction, and it was a reason for complaints and doubts, sometimes we even kept our scores and the resource decreased anyways The workers also question discontinuities in the transfer of resources to the teams, especially between cycles of the PMAQ-AB: We used to receive (money) monthly, then it changed to quarterly, now we don't know, annual...It was a long time, we spent more than a year without receiving, everyone knew that we did not receive PMAQ. (FG1.1)This generates uncertainty for the worker regarding the reception of the incentive, and consequently, discouragement.
The periodicity of the remuneration also expresses a tension arising from the payment for performance in a context of salary squeeze: the workers' expectation that the program should minimize the effects of salary losses is opposed to the management's understanding that, if the transfer is monthly, the bonus becomes a salary replacement, resulting in cutting the incentive logic to changes in performance.This tension also presents itself in the opposition between the individual and collective dimensions of work, with management pressure to individualize evaluation and remuneration, and the resistance of part of the workers in favor of the collective benefit.It was a bargaining process, as if it were a salary increase.And we didn't want to consider the PMAQ as a salary increase.I am saying this technically speaking.(G2) In his view, the initial proposal was to guarantee a bonus to workers related to their individual performance.
The unions brought a lot of examples from other cities.Including the metropolitan region and the interior, which started to use this model of the PMAQ transfer to be divided among the professionals per month, as a salary increase, so to speak.It was a bonus, but it was a value that you counted with, every month [...].And it turned out that PMAQ became an additional resource that the municipality had, to pass on to the professionals, to improve, let's say, the professionals' salaries.And that's what we didn't want [...] to become a salary increase.(G2) This manager also highlights that her annoyance was to remunerate with program resources people who did not deserve it."What bothered me was 'I have to win, otherwise I don't participate'.I didn't see PMAQ as the evaluation process that it is" justified with an understanding of individualized evaluation of the work process."That's good for the worker too.While I'm in, I want my work to be showed, [...] if I'm failing, that I can understand where I'm failing, so I can improve," she adds.Based on this, he understands that the value passed on cannot be conceived as a salary, but rather "a performance bonus" (G2).
At that moment, there was a broad national debate about the labor reform proposal, approved in the Temer Government (2016-2018), with implementation of a new policy that individualizes wage negotiation and dispenses with the intermediation of unions in the employer-employee relationship.Ideologically, despite referring to the PMAQ-AB, a public program, and to the idea of gratification, the local management corroborates the defense of the individualization process of labor relations in counterpoint to its collective dimension, even in public service.
The conflict was also present in Capital 1, despite its solution in favor of understanding work as the result of a collective process.I didn't like the evaluation because, in my opinion, it should be done by each professional, not by team", because then "they would really see the performance of each one, right?No one is better than the other.(FG1.2)This justification of individual evaluation was countervailed in the same focus group, with emphasis on the collective conception of the work process, which prevailed in Capital 1 as a result of workers' struggles.One of the participants pointed out that there are months when the person: Interface (Botucatu) https://doi.org/10.1590/Interface.220436 […] can't perform, and it's not her fault, it happens.It happens with the nurse, with the dentist, we as a team, we owe it to each other.(FG1.2) The municipal bargaining of the PMAQ-AB generated intense conflicts between workers and managers regarding the transfer of resources and the division of percentages among the professionals.In capital 2, the workers boycotted the program, leading to a temporary suspension in the transfer of resources from the federal government to the municipality and a significant reduction after the third cycle of the program (about a quarter of the transfers in the first cycle).In Capital 1, the disputes unfolded into street unrest.
The last time we held a very heavy demonstration, we burned tires, police came down, the municipal guard came down, for the return of the quarterly PMAQ, because at that time we received it annually.[...] It was a big fight that we faced with the management so we could have the quarterly PMAQ again, among other issues as well.(FG1.1) It should be noted that the mechanisms of social participation foreseen by the program reproduce what Fleury and Kabad 32 define as "participation metonymy".In the analyzed contexts, forms of participation prevail "as persuasion" and as "matrix governance", since management mobilizes the formal instances of public deliberation to legitimize previously made decisions, with limited possibilities of incidence.When faced with these situations, the workers develop other forms of participation, which reinstate the conflict as a concrete possibility of distributing public resources in a less unequal way.The subjects collectively define the multiple metonyms that express a terrain in dispute, both material and of meanings.In such a context, the "repertoire of interactions" of the subjects in action goes through consensus building and coercion, "dialogue" and "deceit", bargaining actions, clientelism, or direct confrontation 33 .In this case, the difficulties in the dialogue unfolded into direct confrontation.The "burning of tires" is, in this sense, a new "metonymy of participation" that puts back the dispute of power in the direct relationship between worker and State.
The reports of the research participants must be contextualized in a reality of wage contraction, weak employment bonds, and worsening working conditions, demarcating the PMAQ-AB as a good analyzer of the effects of the distributive conflict underway in the country, thinking of it in the mesosocial dimension of the policy.Based on this differentiation of the different levels of political-social integration present in the observed phenomenon, we have prepared a summary table of the main results.
The political and economic crisis in Brazil has as one of its expressions the aggravation of the distributive conflict, as a result of the wage recovery in the years 2004-2014, with a solution in favor of the capital, through the adoption of austerity policies, contraction of demand, and consequent mass unemployment from 2015 on.For these reasons, the analysis of PMAQ-AB and other programs that contemplate pay for performance must necessarily be contextualized, in order to understand the meanings of the results, only possible by discussing the scenario of disputes over the distribution of the public budget.
The central dimension of the distributive conflict analyzed here is the dispute over the public fund, which occupies a structural place in contemporary capitalism, involving the capacity to mobilize state resources for accumulation processes."The public fund has become a presupposition for financing the reproduction of labor power, globally reaching the entire population through social expenditures" 34 (p. 19-20).The complexification of the productive process, added to the growing financialization of the economy, is what gives state action a precise meaning: "impose" on society "the weight of the exclusive valorization of the most developed economic sector" 35 (p.404) with the destination of public resources to the financial market remuneration and capital reproduction.
The group of "institutional investors" includes "pension funds, collective investment funds, insurance companies, banks that manage investment companies", among others 36 (p.616).The market imposes "new standards of profitability and demands for reduced wage costs, increased productivity and flexibility in labor relations" 36 (p.610-1).The interventionism of the market in the State has a double effect: the channeling of public resources to the private sector and the precariousness of labor relations.Both have a direct impact on social security and, more specifically, on health policies.

Source: Authors
The PMAQ-AB is inserted in this context, representing, initially, an effective injection of new resources at the heart of the policies unleashed between 2011 and 2014, which raised the federal government's overall budget for primary care from R$9.2 billion in 2010 to just over R$20 billion in 2014.Primary care went from representing 13.9% to 18.9% in the overall budget of the Ministry of Health, despite remaining the most underfunded of the SUS health care areas 37 .
These increases were relevant to reduce the underfunding of this sector, especially in the municipalities, which assume disproportionate shares of the investments in primary care, more than 50% of the global investments, with the states assuming less than 10%, and the federal government between 30 and 40% 37 .Thus, the PMAQ-AB represented a relief for local managers, who tried to defray their costs with the new resources.At the same time, the workers continued to fight for better salaries.
The characteristic of the PMAQ-AB that favors the definition of the allocation of resources by the local level 27 , valuing the principle of decentralization, has heightened tensions, as expressed in the speeches highlighted above.The results showed that the dispute for the use of the public fund was displaced to the arena of each municipality, causing in some occasions, to turn negotiation into a battlefield between workers and managers.These tensions worsened when the increase in public resources for primary care was reduced as a result of the fiscal adjustment initiated in 2015 and intensified as of 2016, highlighting the mesosocial scope of the policy in a macro context of de-funding.
Following the Constitutional Amendment 95 (EC-95), there was a reduction of R$ 22.5 billion in federal health resources between 2018 and 2020 38 .The transition from underfunding to de-funding of the SUS shows the intensification of the distributive conflict and its solution in the health sector in favor of capital, with direct impact on local service delivery.The underfunding of social security in Brazil had as some of its causes the tax and fiscal exonerations that, in the health sector, benefit private agents and weaken the capacity of the public budget 31,36 .With the EC-95 and the consequent de-funding of the security, the situation has worsened."Health expenditures are practically frozen, in real terms, throughout the period, presenting a negligible evolution of 0.39%, going from R$ 118.63 billion, in 2016, to R$ 119.10 billion, in values paid in 2019" 31 (p.381).The situation tends to worsen with the approval, in 2019, of new political guidelines of restrictive character for the federal financing of basic care 39,40 .The analysis of the federal public budget also shows that, from 2016 to 2019, there was a greater channeling of resources previously allocated to social security to pay primary expenses with the refinancing of public debt 31 .Thus, the dynamics observed in PMAQ-AB should be contextualized as local and sectoral expressions of the results of the "intensification of the Brazilian public funding dispute," which have been unfavorable to workers."The non-prioritization of social policies within the public budget becomes even more serious in the framework of the accelerated increase in social inequalities, the fall in labor income, and the increase in unemployment" 31 (p.385).Therefore, the analysis of social policies cannot be dissociated from macroeconomic management."As long as social policy is submitted to the logic of permanent fiscal adjustment, there will be no possibility of guaranteeing and expanding social rights, let alone universal social policies" 31 (p.385).
The empirical material analyzed shows the political-social consequences of fiscal austerity under neoliberal rule.The local context exposes the process of individualization of labor relations and the reaffirmation of the meritocratic ideology as a form of individual distinction and justification of inequality.Part of the neoliberal policy is to combat proletarianization through the "entrepreneurialization" of workers, in which "re-individualization" takes center stage in the ideological sphere 3 .There are three combined trends: the replacement of the mass of workers by a "multitude of enterprises", based on the concept of "self-investment portfolio" as a form of social insertion of the individual; the "sharing economy" and outsourcing; and the delegation, to families, of the tasks of providing for dependents 3 .
The State, as seen by the neoliberal lens 41 , is responsible for establishing the space of freedom for individuals to pursue their private interests, and the free economic game is responsible for legitimizing the rules of public law 41 (p.107) This is "far from condemning state intervention as such on principle".The founders of neoliberalism had the "originality to replace the alternative of 'intervention or non-intervention' by the question of what the nature of the interventions should be" 41 (p. 158).That is, it is necessary to differentiate illegitimate from legitimate state interventions, which in neoliberalism are those that stimulate a competitive logic in the mediation of all social relations, no longer restricted to the market.This process is present in the public and private sectors, and the meritocratic ideology is one of the main forms of social legitimization.Inequalities in access to resources and goods are repositioned by the meritocratic discourse, as the result of differences in individual merits.Meritocratism is "mystifying" 42 , because uses the link of health management with remuneration based on individual merit, thus hiding the actions and work relations that effectively operate in primary care.Those work relations are collective and performed in a context of extreme precariousness and flexibilization, with salary reduction, excessive number of users per health team, exhausting work shifts, among other factors that affect the results achieved.The meritocratic discourse seeks to operationalize, on an ideological level, the legitimization of state intervention that aims to stimulate competition as the foundation of social integration, at the same time that it redirects the public budget resources previously destined to remunerate labor, to be directed towards the reproduction of capital.
It is precisely this "promotion of the principle of competition" that ends up introducing, in the neoliberal phase, "an important displacement with respect to classical liberalism: the market is no longer defined by exchange, but by competition.If exchange works through equivalence, competition implies inequality" 41 (p.111).In the case of work in the public service, such inequality can be expressed in two ways, by differentiated access to resources within the system, among people that may deserve it or not; and by differentiated access to state resources, to public funds, in favor of capital and the remuneration of public debt creditors, and in detriment to the remuneration of labor.In the PMAQ-AB, these two consequences of contemporary neoliberal capitalism are present.

Closing remarks
The analysis of the PMAQ-AB exposed the importance of context in the analysis of the implementation processes of public policies.We understand that the combination between the production of empirical material by case study and contextualization is the main potentiality of the research presented here, with limitations related to the difficulties of generalization in qualitative research.
The PMAQ-AB was conceived in an expansive logic of investments in basic health care, but executed in a historical moment of profound political instability and inflection of macroeconomic orientation, transitioning from weak reformism to "strong counter-reformism".This macrosocial process has brought consequences to the forms of collective action and management of public resources (mesosocial level) and to the local organization of the subjects participating in the policy (microsocial level).
The solution of the deteriorating distributive conflict in the country in favor of capital produced a shift in the content of the PMAQ-AB: what was foreseen as payment "per performance" became compensation to mitigate the effects of salary losses.With wage stagnation, the amount received became "an extra income", "some help", in the production of a metonymy in which payment for performance is now understood as wage complementation.This imposed limits on the achievement of the PMAQ-AB objectives, since the planned links between pay and performance were broken, in a context of impossibility to assess merit.This, on the contrary, manifested itself as an ideological justification of the worker's adaptation to the context of worsening working conditions.And so, a new metonymy was produced: meritocracy as the governance of litigation.This process gained more defined contours by contrasting the individual to the collective in the program's pacts.The displacement of the dispute over the use of public funds to the municipal level in a context of budget retraction transformed the negotiations into a battlefield between health managers and workers who, situated in an unfavorable macro-social position, found in the spaces in which they directly participate possibilities of producing effects on the policy and mitigate their losses.At the mesosocial level, the management pressures to individualize the evaluation and remuneration with reference to the discourse of merit as the governance of litigation, and the workers oppose by reaffirming their collective condition as a class, in favor of the benefit as salary recomposition for all.
The combination of the orthodox neoliberal program with authoritarian forms of political conduction leans towards to limit the participation of workers in the management of public policies, with the guarantee of privileged access of the market to public resources.Other consequences of contemporary neoliberal capitalism are the dissemination of competition as a principle of social (dis)integration and the increase of inequalities.In face of this, users, workers and managers are reminded of the importance of a rearticulation around the defense of the principles of the Brazilian Sanitary Reform, as a counterpoint and horizon of struggle for a health that is collective and, necessarily, democratic.