O novo perfil dos gestores locais no sistema de saúde descentralizado no Brasil

Fleury, Sonia; Ouverney, Assis Luiz Mafort

doi:10.1590/0103-1104201811902

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ORIGINAL ARTICLE • Saúde debate 42 (119) • Oct-Dec 2018 • https://doi.org/10.1590/0103-1104201811902 copiar

O novo perfil dos gestores locais no sistema de saúde descentralizado no Brasil

Autoria SCIMAGO INSTITUTIONS RANKINGS

RESUMO

Este artigo analisa o impacto da descentralização sobre os padrões de recrutamento para o cargo de secretário municipal de saúde, visando compreender em que medida o poder local tem sido democratizado, como consequência da implementação do Sistema Único de Saúde (SUS). Os secretários municipais de saúde de todo o País responderam a um questionário em dois momentos diferentes no processo de descentralização - 1996 e 2006 - alcançando resultados representativos. O objetivo era coletar dados sobre seu perfil socioeconômico, profissional, trajetória política e vida pública. Os resultados mostram que há mais mulheres, pardos e pessoas de baixa renda que ocupam o cargo, e que a qualificação de secretário municipal de saúde melhorou no período entre as duas pesquisas. No entanto, isso não se aplica às grandes cidades e regiões mais desenvolvidas, onde a competição por essa posição levou a um padrão de recrutamento que combina altos níveis de profissionalismo com acesso restrito para grupos desfavorecidos. Constatamos também que os secretários municipais de saúde estão agora mais envolvidos politicamente nas associações de gestores do que na sua inserção anterior nas redes da sociedade civil.

PALAVRAS-CHAVE
Sistema Único de Saúde; Descentralização; Governo local

	Less access	More access
Less qualified	Conservative Limited professionalization and renewal	Inefficient Renewal with no professionalization
More qualified	Elitist Meritocratic and elitist - Professionalization without renewal	Democratic Renewal of the elites Professional management

Attribute	Variable	Trend (2006)	Nationwide variation, 1996/2006	Variation by region and size (2006)
Attribute	Variable	Trend (2006)	Nationwide variation, 1996/2006	Region		Size
Social origin	City of origin	Managers born in a different city (64.3%)	Slight reduction (-3.2%)	More	Less	Less intense (60.6%) in cities with over 200,000 inhabitants
	City of origin	Managers born in a different city (64.3%)	Slight reduction (-3.2%)	N (71.7%) and MW (74%)	-
	Education of Father/Mother	Parents with primary education only (66.4%)	Slight reduction (-2.5%)	N (77.7%) and S (70.2)		Increasing percent of parents with more than a primary education: 31.9% (0-5 thousand inhabitants) to 49.2% (> 200 thousand inhabitants)
Current situation	City of residence	Managers residing in the city where they work (82.5%)	No change (+0.4%)	N (97.3%) and MW (95.5%)	NE (69.0%)	No significant change
Current situation	Time residing in city	Managers living in city where they work for over 10 years (74.5%)	Slight increase (+4.7%)	S (81.3%)	-	Increases with city size: 74.4% (0-5 thousand inhabitants) to 82.6% (> 200 thousand inhabitants)
	Monthly wage	Managers making R$ 3.000,00 or less (79.3%)	Slight increase (+1.8%)	N (89.1%)	S (78.1%)	Decreases with city size: 94.1% (0-5 thousand inhabitants) to 1.6% (> 200 thousand inhabitants)
	Other sources of income	59.3% have another source of income	Significant reduction (-15.2%)	NE (66.1%)	S (48.3%)	Increases with city size: 47.4% (0-5 thousand inhabitants) to 67.1% (> 200thousand inhabitants )
Personal characteristics	Age	Managers between the ages of 30 and 50 (64.9%)	Slight reduction (-3.5%)	N (76.9%)	SE (59%)	Decreases with city size: Between 30 and 50 years of age 47.4% (0-5 thousand inhabitants) to 67.1% (> 200 thousand inhabitants) Increases with city size: Between 50 and 60 years of age 11.7% (0-5 thousand inhabitants ) to 46.8% (> 200 thousand inhabitants)
	Gender	Balanced: 50.1% men and 49.2% women	Significant increase in the number of women (+10.4%)	N (58.6%)	SE (45.6%)	More women in smaller cities 49.2% (0-5 thousand inhabitants) to 25.2% (> 200 thousand inhabitants)
	Race	Caucasian (69.3%) or mulatto (26.4%)	Fewer caucasians (-14.9%) and more mulattoes (+14.9%)	N (64.9%) and NE (41.6%)	S (7.2%) and SE (13.8%)	The percent mulattoes decreases with city size: Approximately 27% (0-5 thousand inhabitants) 18.4% (50-200 thousand inhabitants) 9.4% (> 200 thousand inhabitants)
	Marital status	74.6% are married or in a stable domestic partnership	Slight reduction (-2.7%)	MW (82.5%)	NE (69.9%)	Increases with city size: Approximately 74% (0-5 th. inhab.) 80.2% (50 - 200 th. inhab.) 88.2% (> 200 th. inhab.)

Variable	Trend (2006)	Nationwide variation, 1996/2006	Variation by region and size (2006)
Variable	Trend (2006)	Nationwide variation, 1996/2006	Region		Size
Education/ University degree	At least an undergraduate degree (67.3%)	Reduction (-5.7%)	MORE	LESS	Qualification goes up with city size: 49.9% (0-5 thousand inhabitants) to 96% (> 200 thousand inhabitants)
Education/ University degree	At least an undergraduate degree (67.3%)	Reduction (-5.7%)		N (50.1%) and MW (60.3%)
Professional education	Secretaries with degrees in healthcare (44.9%, 11.2% have MDs), the humanities or business (20.3%)	significant reduction in # of physicians (-20%)	Healthcare areas NE (52.8%) Physicians SE (14.8%)	Healthcare areas S (33.9%) Physicians N (5.8%)	Training in healthcare increases with city size: 33% (0-5 thousand inhabitants) to 64.5% (> 200 thousand inhabitants)
Training courses	67.6% have taken courses either focused on the position, in public health (39.7%) or planning (25.6%).	Increase (+8%)		N (56.3%)	Increases with city size: 57.9% (0-5 thousand inhabitants) to 84.8% (50-200 thousand inhabitants) and 79.7% (> 200 thousand inhabitants )
Prior experience in healthcare	73.8% have prior experience in healthcare	Reduction (-5.2%)	MW (79.1%)	S (68.5%)	Increases with city size: 67.2% (0-5 thousand inhabitants) to 89% (> 200 thousand inhabitants)
Experiencing managing a public agency	64.6% have already managed a public agency (37.% only in the healthcare area)	Increase (+8.3% in general, +2.6% in healthcare)	Public AGENCY N (78.4%) Healthcare area NE (44.6%)	Public Agency SE (59.3%) Healthcare area S (28.8%)	Increases with city size: 46.4% (0-5 thousand inhabitants) to 92.9% (> 200 thousand inhabitants)
Prior experience as a municipal health secretary	23.6% had already held the position of health secretary, sometime in the past	Increase (+7.3%)	No significant regional differences		Increases with city size: 17.2% (0-5 thousand inhabitants) to 30.0% (50-200 thousand inhabitants) and 28.3% (> 200 thousand inhabitants)
Prior area of work	67.2% were already employed in the public sector	Slight reduction (-0.5%)	N (77.4%) and NE (76.7%)	S (59.3%)	Increases with city size: 63.4% (0-5 thousand inhabitants) to 77.2% (> 200 thousand inhabitants)
Activities outside the health department	44.2% work additional to their job in the health department	No data for 1996	MW (56%)	N (32.5%) and S (34.6%)	Increases with size: 34.4% (0-5 thousand inhabitants) to 59.6% (> 200 thousand inhabitants)

Attribute	Variable	Trend (2006)	Nationwide variation, 1996/2006	Variation by region and size (2006)
Attribute	Variable	Trend (2006)	Nationwide variation, 1996/2006	Region		Size
Political/Electoral experience	Currently affiliated to a political party	60.4% are affiliated to a political party	Slight reduction (-1.9%)	MORE	LESS	Not related to city size: More affiliated: 0-5 thousand inhabitants (68.4%); Less affiliated: 20-50 thousand inhabitants (49.9)
	Currently affiliated to a political party	60.4% are affiliated to a political party	Slight reduction (-1.9%)	MW (78.9%)	SE (52.1%)
	Time with party	65.9% have been affiliated tor 10 years or less, and 41.1% for 5 years or less	No data for 1996	N (83%) and MW (76.5%)	S (60.2%)	Party member of 10 years or less decreases with city size: 71.2% (0-5 thousand inhabitants) to 62.1% (> 200 thousand inhabitants)
	Running for Electoral office	25.2% have run for public office	No data for 1996	No significant regional differences		Not related to city size:31.8% (0-5 thousand inhabitants)
	Prior experience as an elected politician	18.6% had already been elected to a political position	Slight increase (+2.9)	N (25.7%)	SE (14.1%)	Decreases with city size: 23.2% (0-5 thousand inhabitants) to 13.3% (> 200 thousand inhabitants)
	On leave from elected office	5.6% are on leave from their political office	No data for 1996	N (11.1%)	MW (1.3%)	Drops slightly with size of city: 6.6% (0-5 thousand inhabitants) to 3.0% (> 50 thousand inhabitants)
Experience in health politics	Participation in events	98% have already participated in some political healthcare event	Slight increase (+3.9%)	No significant change		No significant change
Experience in health politics	Involvement in entities and forums	68.9% have been involved in COSEMS 59.2% have been involved in RBIC	No data for 1996	RBIC N (83.4%) COSEMS N (89.1%)	COSEMS SE (60.1%)	Increases with city size: COSEMS/-7.7% (0-5 thousand inhabitants) to +13.8% (> 50 thousand inhabitants) RBIC/-9% (0-5 thousand inhabitants) to +15.7% (> 50 thousand inhabitants)
Experience in associations	Membership in civil societies	67.8% belong or have belonged to civil society associations.	Very significant reduction (-16.2%)	S (78.8%)	SE (63%)	Higher rate of membership in cities of > 50 thousand inhabitants
	Types of associations	Professional associations (25.6%), religious associations (22.5%), social clubs (19.8%) and unions (16.2%)	Social clubs (-21.8%) Professional associations (-18.1%)	Social clubs S (35.7%) Religious associations S (32%) Professional associations MW (34.9%)	Social clubs N (6.9%), NE (12.4%) and MW (12.1%) Religious associations NE (14%)	Increases with city size: Professional associations (18.2%/0-5 thousand to 66%/> 200 thousand) and service clubs (9.6%/0-5 thousand to 25.1%/> 200 thousand). Goes down with city size: Community associations (12.3%/0-5 thousand to 4%/> 200 thousand); religious associations (33.1%/0-5 thousand to 15.8% > 200 thousand).
	Importance assigned by manager	30.4% assign high importance	No data for 1996	MW (41.6%)	NE (23.5%) and N (24.2%)	No significant change

Centro Brasileiro de Estudos de Saúde Av. Brasil, 4036, sala 802, 21040-361 Rio de Janeiro - RJ Brasil, Tel. 55 21-3882-9140, Fax.55 21-2260-3782 - Rio de Janeiro - RJ - Brazil
E-mail: revista@saudeemdebate.org.br

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[1] Contributors

Fleury S and Ouverney ALM contributed to the conduct of research, data collection and processing, and article analysis and writing. ■

1996	Region					Population
1996	N	NE	MW	SE	S	< 5	5 \| 20	20\| 50	50 \| 200	> 200
Number of cities	398	1,558	426	1,533	1,058	1,067	2,544	903	376	83
Number of respondents	78	238	114	563	429	271	661	300	153	37
% of response	19.6	15.3	26.8	36.7	40.5	25.4	26.0	33.2	40.7	44.6
2006	Region					Population
2006	N	NE	MW	SE	S	< 5	5 \| 20	20\| 50	50 \| 200	> 200
Number of cities	449	1,793	465	1,668	1,188	2,672	1,298	1,026	443	124
Number of respondents	43	251	90	420	279	440	232	208	126	77
% of response	9.6	14.0	19.4	25.2	23.5	16.5	17.9	20.3	28.4	62.1