The end of the cooperation government-academy in the National Program for Improving Access and Quality of Primary Care in the Brazilian Nacional Health System

This study analyzes the dissolution of the institutional cooperation, lasting approximately a decade, between the Ministry of Health and a set of academic institutions for the implementation of the National Program for Improving Access and Quality of Primary Care (PMAQ-AB) in the scope of the Brazilian Nacional Health System (SUS). This exploratory, qualitative research consists of a case study that uses assumptions of Historical Neoinstitutionalism to guide the analysis. Data were collected by documentary and bibliographic research and semi-structured interviews with key actors. From the content analysis, three analytical categories were evidenced: end of the PMAQ-AB – historical process, political-institutional context and actors; end of the institutional cooperation – government-academy interaction process; and actors’ perceptions about the end of institutional cooperation. The end of institutional cooperation happened in a context of change of government at the federal level, within a new political-institutional order of SUS and was influenced by historical factors and the practices of public managers and in the conduct of political processes. An inter-institutional government-academy exchange with a view to strengthening health management and supporting the institutional development of the SUS is a future expectation, considering the adversities imposed on the field of health and public education in Brazil today.


Introduction
The New Public Governance paradigm, especially since the 2000s, has influenced public managers to offer higher quality services to citizens (Pereira et al., 2017).In the health field, there is an increase in policy-making processes through formal articulation with academic institutions, with the perspective of implementing innovative programs to obtain better results in the Unified Health System (SUS).This stems from the complexity of integrating scientific knowledge with public health policies from the perspective of Evidence-Informed Policy (PIE) (Ramos;Silva, 2018).
In Primary Care (PC), in the last two decades, the Ministry of Health (MS) has become closer to Teaching and Research Institutions (IEPs) (Facchini;Tomasi;Thumé, 2021;Primary Health Care Research Network, 2018).In this context, in 2011, MS engaged in institutional cooperation with Brazilian PEIs as part of the political-institutional initiatives to implement the Program for Improving Primary Care Access and Quality (PMAQ-AB).The program aims to induce changes in health management and care, to improve access to services and raise the quality of care offered to citizens.To this end, the transfer of federal funds to the municipalities was tied to the performance achieved in the nationally predefined evaluation processes (Cavalcanti;Fernandez;Gurgel Junior, 2021).
According to Cavalcanti, Fernandez and Gurgel Junior (2021), this cooperation provided the formulation and operationalization of the external evaluation of PMAQ-AB, as well as the development of management support and academic activities, considering the IEPs' knowledge about the SUS and PC, and their expertise in evaluative research.It has also provided a greater degree of impartiality, legitimacy, and credibility to the evaluation process of the program, mainly due to the pay for performance.However, in 2019, the PMAQ-AB and, consequently, the government-academy cooperation were terminated.
Currently, there are no scientific studies that explore historical circumstances, with emphasis on political-institutional events that can lead to discontinuity in policies (Nogueira, 2006), and their effects on this cooperation.Thus, the purpose of this article is to contribute to a better understanding of the dissolution of this institutional cooperation, which lasted for about a decade and spanned several MS administrations, between the country's health authority and a set of IEPs for the implementation of PMAQ-AB.The perspectives of the institutional actors of SUS who have expressed opinions about the end of this partnership will also be considered.

Historical Neoinstitutionalism as a reference to analyze the end of government-academy cooperation in PMAQ-AB
Historical Neo-institutionalism (HN) considers the role of institutions in shaping actors' actions and sustaining policies, while valuing other conditioning aspects of policy formulation and implementation processes, such as actors, their interests, and strategic actions (Immergut, 1998); socioeconomic developments; and ideas (Hall;Taylor, 2003).Institutions comprise the formal and informal rules inherent in the organizational structure of the political community, which mediate relations between actors.In this sense, they provide actors with moral and cognitive models that enable interpretation and action, while influencing their preferences, identities, and goals (Hall;Taylor, 2003;Pierson, 2000).
According to North (2018), the outcomes of public policy are contingent and dependent on the struggle and strategies outlined by various actors, in the social and political space in which they interact.In the political dispute arena, decisions originate in political and social processes influenced by institutional factors and the often conflicting interests, worldviews, and ideas of the actors (Immergut, 1998).Thus, the combination of processes undertaken by institutions and actors with decision-making power is capable of directing the strategies adopted within the scope of public policies, which determines path dependency (Pierson, 2000).
One understanding of the term explains that the choices made at a given historical moment condition later choices, while constraining many others (Immergut, 1998;Pierson, 2000).That is, past choices exert a constraining effect on the future through the continuity of a society's institutions (North, 2018).This premise points to an inertial trend in institutions.Once a path is adopted, the political and economic costs of changing it are usually high (Immergut, 1998;Pierson, 2000).However, it is admitted that the trajectory of institutions and public policies is also marked by historical sequences and contingencies, in which elements capable of provoking variations and ruptures are present, in terms of trajectory or subsequent results (Pierson, 2000).
The change in trajectory can be interpreted as an effect of exogenous factors, related to the structure of institutions and the institutional environment, which cause a rupture in historically verified and reinforced action patterns, characterizing a critical moment or a critical juncture (Pierson, 2000).These are situations of political or economic transition that enable the reconfiguration of political processes and the exchange of institutions for new ones, which, in turn, favor changes in politics (March;Olsen, 2008).Another sense is based on incremental change, whose explanatory aspects of intra-institutional dynamics, especially related to the action of actors, can induce significant transformations in the policy trajectory (Mahoney;Thelen, 2010).
Institutions matter from the perspective of changing or maintaining the status quo and must be analyzed in association with historical facts, in a longitudinal sequence.History matters, as knowledge about it can elucidate how events connect and relate to each other while determining the course of politics (Hall;Taylor, 2003;Pierson, 2000).Therefore, in this article, the historical-institutional approach is useful to investigate factors that had repercussions on the trajectory of dependence of institutional cooperation between MS and IEPs, established from the PMAQ-AB, through the political-institutional characteristics of the time, considering the role of institutions and actors in the formulation, decision and implementation of public policies.

Methodology
This exploratory, qualitative research consists of a case study that uses assumptions from NH as a model for policy analysis.Given its complexity, we sought to combine methods and data collection sources, aiming to obtain information from different angles or points of view, to develop convergent lines of investigation and enable a triangulation process.This strategy limits personal and methodological biases, contributing to the validity of the research (Minayo, 2014).
Initially, the analyses on PMAQ-AB showed that several aspects related to the participation of IEPs in the cooperation, from the selection criteria to the factors that led to the suspension of the cooperation, were not explained by MS in official documents.To achieve a better understanding of the political-institutional context of the Federal Government, a complementary documentary and bibliographic research was conducted.
This study used scientific articles found in the databases of the Virtual Health Library (BVS), the Scientific Electronic Library Online, and the Periodicals Portal of the Coordination for the Improvement of Higher Education Personnel (Capes).The search was conducted by the terms "PMAQ-AB", "Avaliação Externa", "Programa Previne Brasil" (substitute to PMAQ-AB).Furthermore, we used publications of various natures (interviews, reports, news, articles, and texts), published in the media and by entities in the field of public/collective health.
The methodological option for allocating individuals in the research sought to ensure adequacy to the predefined purpose.Therefore, it was not based on numerical representation per se, but considered obtaining satisfactory elements to deepen the knowledge about this cooperation, aiming to enable profitable interpretations and inferences, ensuring a sufficient number of participants, considering the saturation point (Minayo, 2014).Therefore, the interviews focused on key actors, who certainly have fundamental information about the context and the social and political-institutional dynamics related to the object of study, due to their institutional involvement in the process of implementation of PMAQ-AB via government-academy cooperation.
As a selection criterion, MS representatives who held a management position in the area of primary care between 2011 and 2019 were sought.Researchers and representatives of the "main" IEPs participating in the National Coordination of External Evaluation (the national space for cooperation interaction) were also sought.The "main" IEPs are of interest because of the institutional involvement in the initial negotiations for the effectiveness of the cooperation under the PMAQ-AB.They received financial resources and led the operational processes for the execution of PMAQ-AB, while some formed consortiums with similar institutions (Cavalcanti;Fernandez;Gurgel Junior, 2021;Facchini;Tomasi;Thumé, 2021).The study also included representatives from the National Council of Health Secretaries (Conass) and the National Council of Municipal Health Secretaries (Conasems).
Representatives of IEPs from partner institutions who did not participate in the initial negotiations for this cooperation were not considered.Local representatives from states and municipalities were not invited either.Although it is recognized that in the SUS governance space, in the Tripartite Interagency Commission in which negotiations about national health public policies take place, there is an imbalance of power among the federated entities and gaps in institutional representation (Pires, 2019).
Subjects were invited to participate in the survey by e-mail.The semi-structured interviews, conducted using a specific script for each interviewee profile, took place from March 6 to July 30, 2020, remotely.Thus, it was possible to conduct nine interviews with the key players: three with MS leaders, four with researchers from IEPs, one with a representative from Conass, and one with a representative from Conasems.
Among the interviewees, the managers had at least a master's degree and nine years of experience in SUS management.The researchers had at least a PhD degree and academic experience with varied publications on SUS and AB.The Conass and Conasems representatives had at least a master's degree and more than eight years of experience in their respective entities.The anonymity of the interviewees was guaranteed using the term "G", representing the national SUS managers, and "IEP", for the representatives of the academic institutions, plus an Arabic numeral, arranged from one to nine.
The data approach was based on the content analysis proposed by Bardin (2015).The pre-analysis comprised the organization of the obtained materials with the purpose of operationalizing and systematizing the preliminary ideas.The floating reading of the collected documents allowed an understanding of the content that helped in the choice of documents to be submitted to the analysis, and in the elaboration of indicators to support the final interpretation.
In the material exploration stage, we sought to reveal characteristics of the content by identifying analytical categories, defined in the light of the NH precepts.The formulation of the analysis categories also emerged from the research corpus, to contemplate all the themes evidenced in the documents and interviews.The final categories defined in the study are: end of the PMAQ-ABhistorical process, political-institutional context, and actors; end of the institutional cooperationgovernment-academy interaction process; actors' perceptions about the end of the institutional cooperation.The last step was based on the evidence found to perform a content interpretation and respective understanding of the meanings.

End of PMAQ-AB: historical process, politicalinstitutional context and actors
"The end of institutional cooperation was a consequence of the termination of PMAQ-AB [...]" (G-4).This statement highlights the interrelationship of these processes.For a better understanding, we will highlight political-institutional and technical aspects that influenced the decision-making processes about the PMAQ-AB, in the spaces of political interaction and negotiation in the national sphere of SUS management.These factors had repercussions on cooperation, given the importance of external evaluation and pay for performance for the implementation of the program nationally.
According to the evidence, historically, the PMAQ-AB was initiated in the government of Dilma Rousseff (2011Rousseff ( -2016)), in the context of the revision of the National Policy for Primary Care (PNAB), in 2011, with expansion of funding for the area.The political option of MS leaders was to sign cooperation with IEPs, starting with the support of the Primary Health Care Research Network (Rede APS), from the perspective of producing knowledge and information to support decision making and formulation of health policies (Rede de Pesquisa em Atenção Primária à Saúde, 2012).
During the implementation of PMAQ-AB, important political-institutional changes in the Federal Government impacted MS policies.Documentary evidence shows that in 2016 there was a "climate of vagueness and slowness" in terms of the continuity of external evaluation, resulting from the "institutional crisis" observed in the Federal Government (Silva, 2016).After the impeachment of President Dilma, in Michel Temer's administration (2016)(2017)(2018), the PNAB underwent a new revision in 2017.Despite this, the PMAQ-AB was continued.In 2018, the APS Network (2018) stated that PMAQ-AB and performance-based incentives were at risk of discontinuity in SUS due to financial constraints arising from Constitutional Amendment No. 95 (EC 95) of December 15, 2016.
However, only in 2019, under the Jair Bolsonaro government, the PMAQ-AB was replaced by another program and, at that time, the government-academy cooperation was terminated.There was an important institutional change in MS and in health policy, especially in financing.The following statement reinforces the shortage of financial resources for health care as a reason for the end of the PMAQ-AB, as well as ideological divergence of a party-political nature.

The interruption of the program is related to the shortage of financial resources for health care.
As PMAQ-AB was an extra resource, a variable basic care floor, it was easier to move to adopt government-branded programs [...].There is also a very strong ideological issue in this government, whose political decisions are based on ideology and symbolic dispute with those understood as adversaries: real actors or symbols (from the left, the Workers' Party (PT), previous governments, etc.).Therefore, some initiatives were important to be deconstructed, such as the PMAQ-AB, the Mais Médicos Program [...] (G-3).
Documents and interviews highlight two main interconnected reasons for the end of the cooperation.One of them is related to the institutional change in MS in 2019, when there was an ascension of actors opposed to PMAQ-AB to high-level institutional positions in the hierarchy, especially in the management of the Department of Primary Health Care (DAB/MS), a sector later called the Secretariat of Primary Health Care (SAPS/MS).Associated with this is the conflict of groups: 2011 ministerial leaders and 2019 ministerial leaders.The basis of the dispute is based on the dissonance of conceptions concerning public health policy and epistemological understanding about evaluation, its procedures and methods.These factors were determinant for the interruption of the program and have express correspondence with the cooperation.Some leaders who took over the DAB-MS in 2019, in the Bolsonaro government, were part of the APS Network in 2011 and participated in the initial discussion agendas of the PMAQ-AB.As researchers, they were invited to help in the construction of the program and participate in the external evaluation, but refused, as they advocated another conception and evaluation method (G-1).
According to the Escola Politécnica De Saúde Joaquim Venâncio, of the Oswaldo Cruz Foundation (EPSJV/Fiocruz) (Antunes, 2019), and deponents IEP-3, G-1, G-2, and G-3, the PMAQ-AB formulation process in 2011 was historically marked by controversies regarding its fundamental elements.On one hand, MS proposed the PMAQ-AB and the use of its own evaluation instrument, based on the Primary Care Assessment Tool (PCATool) and other tools.On the other hand, some researchers and members of the APS Network and the Brazilian Society of Medicine Family and Community (SBMFC) were against the initiative.They advocated the use of PCATool as an evaluative instrument, validated with support from Professor Erno Harzheim of the Federal University of Rio Grande do Sul, who held the head of SAPS/MS (2019-2020), and members of the SBMFC.The entity also suggested differentiated payment for family and community doctors (G-3).These proposals were not accepted by the MS managers at the time.Thus, the proponents refused to participate in the construction of the PMAQ-AB and the external evaluation, becoming opponents and critics of the program.
The following reports evidence that, by means of the new institutional conjuncture this dispute, which occurred during the initial negotiations of PMAQ-AB, contributed to sharpening the processes of rupture in 2019 between MS and IEPs, which formally supported the initiative.
Several members in SAPS did not participate in PMAQ-AB [...] in a way they were opponents of groups of researchers involved in the program.These factors, to a large extent, contributed to the end of the partnership.The termination decision was aimed at deprioritizing this group of IEPs (G-1).

Since the arrival of new management in 2019, MS has closed itself off to the university, not just the AB area. This managing group has never liked these IEPs [...] They completely despise them and fail to understand their role in this cooperation. (IEP-2).
Analyzed materials present justifications announced by MS officials for PMAQ-AB replacement.The main aspects refer to the evaluation methodology, the external evaluation instrument and its limitations, the periodicity of the evaluations, the selected monitoring indicators, the adherence criteria of the teams (including voluntary participation in the program), the dependence on contracts with universities, and the questioning of managers about the evaluation results (Harzheim, 2020;Sellera et al., 2020;Roda de Conhecimento, 2019).
Excerpts from the interviews emphasize problems associated with the work of academic institutions regarding the execution of the evaluation by IEPs in states other than their place of origin, as well as doubts of managers about the interviewers' capacity and attitude.On the subject, Conasems (2020) explained that: During the operationalization of the evaluation cycles of PMAQ-AB, mishaps occurred, such as delays in the evaluation of the teams in some states, questioning about the results, requests for reconsideration of the methodology employed, among other aspects.These situations are normal and are part of the maturing of strategies that must be improved over time.
Thus, there was no request from the national representations of the states and municipalities to suspend the program and institutional cooperation.At each cycle of the program, MS, Conass, and Conasems worked together, aiming to qualify the methods employed in the evaluation process (G-1, G-3, G-4, and G-5).However, technical-political aspects favored the tripartite agreement for the replacement of PMAQ-AB.
Conass and Conasems wanted PMAQ-AB to be improved with fewer indicators, and were preparing a proposal to this effect.However, MS brought another proposal (initial bases of the Previne Brazil Program (PPB)) based on a lean list of health indicators, with a more flexible methodology to reach the results, linked to funding, which was accepted in the tripartite negotiation [...].These entities were not against universities.It was not about who was going to do the external evaluation, the problem was the methodology of the program.(G-5).
Also in 2019, MS proposed the PPB, which constitutes the new federal funding model for AB.Replacing PMAQ-AB, the payment by performance component was included and PCATool was defined as an evaluative tool (Brasil, 2020).
In 2019, with the rediscussion of federal funding for AB, Conasems defended the need to maintain a federal funding component that prioritizes payment by performance of the AB teams, understanding that the end of PMAQ-AB without the existence of a corresponding strategy would bring a setback to SUS.Thus, the 'payment for performance' component was discussed and proposed, which is part of PPB.(Conasems, 2020) Although there are criticisms of the negotiation process around PPB, such as the absence of broader debates and the disregard for the opinion of researchers, entities in the health field, and the National Health Council (CNS), in addition to arguments about the risk of reducing financial resources for municipalities (Neves; Machado, 2019; Rede de Pesquisa em Atenção Primária à Saúde, 2019), the program was pactuated at the Tripartite Interagency Commission (CIT) in 2019.

End of institutional cooperation: governmentacademy interaction process
The interviews revealed that the termination of the cooperation was decided by the MS management, through a process marked by the absence of debate.There was no formal communication or meeting invitation from the ministerial authorities to the IEPs to inform about the end of PMAQ-AB and the decision to terminate the partnership.

There was no meeting invitation, communication or contact to inform that the MS was terminating PMAQ-AB and no longer needed the IEPs [...]. It was simply a total and complete indifference [...],
an authoritarian process.Some of the researchers learned through WhatsApp messages with information from the National Congress of Family and Community Medicine (CBMFC) (2019), when it was announced by the MS that PMAQ-AB would be terminated.The PMAQ-AB project was finished, including the qualitative evaluative study, the reports delivered to MS, but there was no debate about that either (IEP-2).
There was never an invitation to the universities to meet in Brasilia and discuss [...] The disclosure of the end of PMAQ-AB occurred through news from the media and social networks, without any previous conversation with partner IEPs.Since the cooperation existed, this decision was totally authoritarian, without consideration and appreciation of the role of universities.(IEP-3).
The MS group decided not to continue PMAQ-AB and the relationship with the IEPs, disregarding about nine years of work by dozens of IEPs in this project with DAB/MS.Everything that was produced no longer had value for thinking AB [...].This process occurred without any dialogue with the IEPs cooperating until then with the department (IEP-4).
The following statement emphasizes the lack of dialogue between national managers and IEPs in conducting this process of concluding institutional cooperation.

The institutional cooperation could have had a better ending, with a presentation by MS at the CIT, as an accountability, about the results and advances of the program, including the IEPs in this debate [...]. There were partners and suddenly the cooperation was terminated. I am not aware of any formal meeting between the partners to discuss the results of PMAQ-AB(G-5).
As stated by the interviewees, there was a movement of leaders of the IEPs seeking dialogue with the ministerial authorities.The purpose was to try and maintain the government-academy rapprochement in order to elaborate evaluative strategies for AB.

There was an expected positioning of the interlocutors of IEPs who sought dialogue with the management of SAPS, the main responsible for decisions about PMAQ-AB and cooperation [...].
The conversations that did happen were one-off episodes, with one or another actor from IEPs [...].On these occasions, the researchers even exposed the legacy of PMAQ-AB, what had been produced so far, and the benefits of the program and the partnership between the government and the academy for AB, both for the care and management dimensions (G-2).
As there were SAPS leaders involved in activities related to AB in academy, the researchers who are members of the National Coordination of the External Evaluation of PMAQ-AB (governance forum of the cooperation) sought, on their own initiative, an approach and dialogue aimed at maintaining this link between IEPs and SAPS/MS.Although no longer in the program, but in the perspective of building new evaluation proposals for AB, since no one disagrees with the importance of maintaining monitoring and evaluation actions for AB in Brazil (IEP-4).
According to the narratives, in an informal meeting between the cooperating institutions, MS representatives stated that the proposal was to replace the cooperation model with IEPs by a cooperation between the Brazilian Institute of Geography and Statistics (IBGE) and the Organization for Economic Cooperation and Development (OECD) to conduct evaluative research on AB in the country.After that, there was no opening for dialogue about the partnership.

Perhaps the only direct conversation with MS leaders occurred at CBMFC (2019). When the scholars present asked about PMAQ-AB,
the answer was that it would be suspended.They informed that, replacing PMAQ-AB, an evaluation would be carried out to reward the teams' performance, based on a reduced set of indicators evaluated over time.This evaluation would be subsidized by international universities and based on the proposal developed by the OECD, using PCATool, and for data collection IBGE would be employed.After the evaluation, the databases would be made available, as they were in PMAQ-AB, and universities would have access to the data to continue producing knowledge [...] then, there was no other conversation, although leaders of the IEPs signaled that they would like to have an official conversation with MS about PMAQ-AB (IEP-3).
The following statement corroborates the previous interview excerpt: Replacing the cooperation, another one was proposed with IBGE, with the objective of resuming the National Health Survey and the National Household Sample Survey, including the PCATool as an evaluation instrument, to provide a portrait of the structure of the health services of AB [...] continuing the picture that PMAQ-AB produced in three evaluation cycles.(G-2).
Analyzed documents (Brasil, 2019;Harzheim, 2020) also describe the strategies of the ministerial authorities: to perform the historical rescue of IBGE as the major external evaluator of public health policies in Brazil.From the formalization of the technical cooperation term, with the application of permanent resources, aiming to expand the component of AB in the demographic-based surveys that already exist in the country, besides establishing an unprecedented agreement with the OECD to carry out two major national evaluations in SUS, to be conducted by researchers linked to the international institution.
Managers and scholars argued that, in this context, no alternative was offered by the MS to continue with the institutional cooperation.

There was no alternative to continuing the cooperation [...]. The requests for IEPs to finalize stages of the project were granted and the funds transferred. But there was no proposal to use that network of IEPs for another purpose or to work on some other aspect of performance evaluation and AB. So far [July 2020], no other role or benefit of the cooperation has been thought of for another purpose or for something similar to what existed in the PMAQ-AB. (G-2).
In the conversation at CBMFC ( 2019), the MS representation said they could think about other relationships with IEPs.But then there was no call for conversation.They talked about possibilities, but no offer.The proposal was to open research calls, according to the needs of MS, and the universities interested in qualifying, in the "counter model", as traditionally occurs, but not in the lines of cooperation with a set of IEPs, as in PMAQ-AB.(IEP-4).
The interviewees mentioned that it remained for the IEPs to complete the administrative formalities related to PMAQ-AB, in order to receive the remaining financial resources."Some IEPs had not received all the resources linked to PMAQ-AB and the qualitative study [...].After submission of the reports, the funds were released."(IEP-2).

Actors' perceptions on the termination of institutional cooperation
The MS decision to suspend the cooperation was seen as a loss for SUS, with reflexes on health management and academic activities in health.The testimonies indicate that this measure characterizes an initiative to weaken democratic institutions and dismantle public policies, in the context of the current Federal Government.

The end of PMAQ-AB and the cooperation was a huge loss for SUS and for the health training that universities offer. But the discontinuity must be analyzed in the context of the initiatives of depletion of public policies, the fight against science and technology, and the weakening of democratic institutions that we are currently experiencing. (IEP-1)
This disruption is very sad, but it is consistent with the policy of the current Federal Government.The government is deprioritizing and making a very strong attack movement on the universities, because it has seen them as an adversary.As has MS, since it made a set of policies that are criticized by the academy, researchers in the field of health, AB, collective health, etc., and by entities from the health reform movement.(G-3) The following statements assert that the termination of the cooperation dismantles and weakens the established relationships between government and academy in SUS.
The main loss was the rupture of the relationships that had been formed from the PMAQ-AB over the years.That was the most disastrous and negative thing within this decision to end the program [...].The end of institutional cooperation was a loss of opportunity for all [...] of the listening capacity, the perspective of the manager and the members of the IEPs who are dedicated to studying and researching AB in Brazil.And, therefore, they have analysis and notes on the subject (IEP-4).
This process was a disrespect, a complete disregard for the institutional relationships that were built by PMAQ-AB.[...] These universities have collaborated on MS projects since the mid-1990s, it's almost 30 years of collaboration, and as for the closure of PMAQ-AB (which corresponded to the partnership from 2011 to 2019), they received no explanation.(IEP-2).
I think it weakens the relationship between MS and these actors in the academy that work in defense of AB.These researchers write about AB and advocate from an academic point of view, with evidence, and train health professionals.If the relationship between MS and these actors is not harmonious, this ends up compromising the public policy [...] I think that this relationship is strained.Currently, there is a tensioning space that does not favor the counter-hegemonic agenda of AB to strengthen it as a priority in the consolidation of SUS (G-1).
The end of the cooperation was also interpreted as a modification in the government-academy interaction model, focused on the needs observed by MS.
The institutional cooperation with this continuous design has ended, but the possibility of cooperation doesn't, because there was a legacy of production from some of these institutions, which allows a partnership to be resumed on another occasion, with a specific purpose.MS always need research or integration of academy and services, and so it celebrates decentralization terms.(G-2).
According to the interviewees, the end of the cooperation weakens the research agenda in AB.This has negative repercussions for the development of scientific knowledge aimed at improving this area of SUS.
The end of PMAQ-AB represents the interruption of continuous and permanent funding for PEIs to produce research related to AB, which weakens the construction of scientific knowledge.[...] Considering that the AB is counter hegemonic in Brazil and one of the aspects that gives greater relevance and strength is to have research and people who are dedicated to defending the AB, not only from the point of view of public policy advocacy, but from the perspective of its qualification.(G-1).

The program's databases are very important for the production of reflections, analyses, publications, etc.
There will still be residual knowledge production from PMAQ-AB, for a while, but it will not be continued (IEP-3).
The end of the cooperation is reflected in the loss of data from the external evaluation, which generated important information for thinking about public health policy and subsidizing the decision making of managers at the federal level, based on the integration between science and policy in the sense of IEP.

With the end of institutional cooperation and the suppression of the external evaluation, important information about AB to support decision-making in federal management is lost, considering that PPB indicators have limitations to evaluate AB and to obtain a reliable picture of the reality. (G-2).
The concern of the interviewees with the end of this government-academy approach was also observed, as its impact on public health policies, in face of the current challenges of SUS.
I evaluate it as a great loss [...] for MS, for SUS, for AB, for family health, and for the universities, for research, for graduate studies, and for personnel training [...].And nothing was put in place and there is no prospect that something of this magnitude will be put in place.[...] We are going backwards and, with the departure of this MS management (in 2020), in addition to the things that were destroyed, we do not see the implementation of the novelties and supposed criteria that would be defining as requirements for the implementation of PPB.(IEP-3).
It has not been possible to mature, from PMAQ-AB, how to involve the university in the evaluation process of the PPB.Thinking about the production of knowledge, the construction of policies and the perspective of human resources training for AB, somehow it will be necessary to rediscuss this role of the academy in a tripartite way, especially in the current scenario of the Covid-19 pandemic, which brings new challenges for SUS and universities [...].Therefore, universities have to be involved in this evaluative process of AB. [...] Only from the results of indicators will it be possible to evaluate performance and quality?No. (G-4).

Discussion
This research shows the importance of the political-institutional context and actors in the closure process of government-academy institutional cooperation in PMAQ-AB, as explained by NH (Hall;Taylor, 2003;Pierson, 2000;Mahoney;Thelen, 2010;March;Olsen, 2008).The historical trajectory of this cooperation has been dependent on previous initiatives of approximation between government and academy in SUS, intensified during the PT governments at the federal level in the 2000s.The end of the partnership involves the rupture of the dependency trajectory, when it is possible to identify the causal mechanisms correlated and characterized by a critical juncture that generated a turning point for the cooperation (Pierson, 2000), but also by incremental changes triggered by public policies (Mahoney;Thelen, 2010).
The critical juncture reflects the historical moment of the institution of a new government in Brazil in 2019, of a political position distinct from that of the immediately previous governments (of the PT), whose political projects move in opposite directions (Cohn, 2020).The political-institutional dynamics produced in this new context allowed for the redefinition of institutions, as well as modifications in SUS public policies and in relations with other sectors of society, as can be expected in situations of institutional change, according to March and Olsen (2008).
Similar to the creation of PMAQ-AB in 2011, its closure depended on a window of opportunity (Nogueira, 2006).The program had already been resisting the Temer government's political-institutional changes, for example, the adoption of EC-95, currently in force, which negatively affects the financing of health and education policies.Another change was the revision of the PNAB, target of criticism from several entities and actors in public/collective health.The legacy of these measures adds to the political and budgetary priorities set by the Bolsonaro government in 2019, inaugurating a new context, which has enabled more intense transformations in SUS.In AB, there has been a shift in the model of financing and payment by performance, which replaced PMAQ-AB with the PPB (Rede de Pesquisa em Atenção Primária à Saúde, 2019;Morosini;Fonseca;Baptista, 2020).
The end of the government-academy cooperation in PMAQ-AB, as a reflection of the alternation of government at the federal level and of political-institutional changes, is a common problem in the public sector in Brazil.In this case, the change of public managers in senior management tends to generate discontinuity of public policies and, almost always, the party-political bias prevails over other aspects, including technical ones, according to Nogueira (2006).In the same direction as Rede APS (2019), Ferla (2020) and Facchini (2020), this research reveals that the interruption of this partnership is not an isolated event, but something that extrapolates the political-institutional processes of SUS.It reflects the phenomenon of discontinuity of Brazilian public policies in general, led by the country's current administration, which began in 2019, and whose political project is to restrict social policies, especially in the fields of health and education (Cohn, 2020).In this sense, Ferla (2020) states that the discontinuity of the external evaluation of PMAQ-AB was processed in MS by a political group, not only because of technical issues, but because of divergence in policies.
It is noteworthy that the policy options or initial choices regarding the program evaluation process constituted the genesis of a group conflict, due to divergent conceptions, perspectives, and policy positions of the actors (Hall;Taylor, 2003;March;Olsen, 2008).One of them was the political option for government-academy cooperation to make PMAQ-AB effective, assumed initially and sustained over the years by a political coalition.But in the face of a new conjuncture, with the change in the relative position of the actors, in terms of power and preferences about health policy, it was modified with the arrival of a new political group, which favored the suspension of cooperation (Pierson, 2000).
The decision to discontinue the cooperation promotes distancing between the actors of MS and the academy.Tomasi, Nedel, and Barbosa (2021) interpret that today there is a divorce between SUS management and academia, a fact that makes a systemic action impossible and allows observing that the important results obtained with the institutional partnership have been discontinued in the current national political scenario.
This move by MS goes against contemporary practices, which aim to achieve better results in politics.We start from the premise that PMAQ-AB is a strategy with roots in more general movements to incorporate management by results in public administration.The focus of the program, aimed at improving the processes of the AB policy linked to the granting of financial benefits, translates the managerialism mode of operation, promoted in the management of public policies from the 1990s in Brazil.Also, in order to meet collective interests efficiently, government-academy institutional cooperation in PMAQ-AB consists of an alternative sharing of responsibilities that characterizes New Public Governance (Pereira et al., 2017).
The government's investment in a closer relationship with the academy and with each other, is the mark of this institutional cooperation of PMAQ-AB, with recognized positive effects for SUS.This articulation, as a support to the policy of encouraging access and quality of AB for payment by performance, not only ensured the effectiveness of the program nationally, but also guided the construction of public health policies in the country, based on information that helps public managers in the decision-making process and generates benefits for the whole society (Cavalcanti;Fernandez;Gurgel Junior, 2021;Facchini;Tomasi;Thumé, 2021;Ferla, 2020; Rede de Pesquisa em Atenção Primária à Saúde, 2018;Tomasi;Nedel;Barbosa, 2021).Therefore, this cooperative process has enabled greater integration between policy and science, in addition to the thickening of scientific knowledge and information for prompt use of the results for the improvement of the AB, in order to foster the development of IEPs (Ramos;Silva, 2018;Primary Health Care Research Network, 2019;Facchini, 2020;Cavalcanti;Fernandez;Gurgel Junior, 2021).
The end of the cooperation occurred in a process marked by the absence of dialogue between MS and the partners in academy.Similar dynamics were highlighted by Morosini, Fonseca and Baptista (2020), when analyzing the political process of the creation of PPB, which occurred simultaneously with the end of the cooperation.According to the authors, the absence of interlocution, face-to-face participation, and representation of political actors has damaged public debate and hidden dissent, which "to a critical eye reveals the problems in the meaning and manner of doing politics."Likewise, the National Health Council, users, and workers were absent from the debate (Neves;Machado, 2019;Morosini;Fonseca;Baptista, 2020).
Finally, the intention of this research is not to disregard the legitimacy of the government to act in the field of public health policies, according to its preferences and interests, even more so when there is express agreement with national representative bodies of SUS managers.Nor is the competence of the IBGE and the OECD in evaluative research questioned.As previously explained, the purpose of this work is to contribute to a better understanding about the dissolution of this government-academy institutional cooperation for the effectiveness of PMAQ-AB in SUS.

Final considerations
This research evidences that the end of institutional cooperation was processed within the political-institutional context of SUS, permeated by historical interferences that impacted the practices of public managers and the conduction of political processes.This scenario was strongly influenced by previous events, with effects on the future of the cooperation.Historically, academic institutions have collaborated in the evolution of Brazilian public health, from the sanitary reform movement until the moments after the creation of SUS.But in this process of ending the institutional cooperation in PMAQ-AB, dozens of partner IEPs were removed from the discussions regarding health policies.
It is also worth mentioning that, because it intends to capture more subjective aspects related to the interruption of cooperation, this article has limitations.Among them, one can mention sampling, which, due to the way the participants are selected, does not allow generalizations.In addition, the study does not capture the understanding of state and municipal managers about the process, limiting itself to the view of Conass and Conasems representatives.One difficulty in carrying out this work is related to the scarcity of studies that address the closure of PMAQ-AB, even more from the NH perspective or from another analytical approach from the field of Sociology.This is an initiative of approximation and dialogue, in order to contribute to the scientific knowledge about the discontinuity of policies in the field of Brazilian public health.Therefore, this work does not intend to go into all the aspects related to the theme, which would be justifiably impossible.
Still, the contributions of this research open an interesting window for further studies on SUS policies and programs, considering the political-institutional context of the country and the health field.In addition, they can also reflect on the performance of health authorities in the process of implementing public policies and their forms of interaction with sectors of society.This study especially reinforces that knowledge of past history allows for a better understanding of the present and foreshadows future developments, as NH points out.
The establishment of a process that brings together SUS and the academy will also depend on a context of political transformation and change of paradigm of public managers that, among other issues, values the power of this juncture as a collaborative network for the implementation of initiatives to improve the PCU, given the complexity and challenges of SUS.And that it also considers the effects of an interaction between the health and education subsystems for the development of research and for health training in schools.Therefore, an inter-institutional exchange for the development and execution of projects aiming at strengthening health management and supporting the institutional development of SUS, are future expectations.Considering the adversities imposed on the field of health and public education in Brazil today.