Systemic integration of dental care in the Care Network for People with Disabilities: a multiple case studyAbstract
It aimed to describe the extent of the systemic integration of dental care in the Care Network for Persons with Disabilities (RCPD), in six Brazilian health regions. Multiple case study with document analysis and interviews with key actors between 2019 and 2021. The categories used were funding, potential coverage of oral health services, coordination of primary care, evaluation/monitoring, integration with the public network, integration with the private and philanthropic network, information and governance system. All regions implemented oral health services followed at the three levels of care and the extent of systemic integration showed different characteristics among regions. The congruent and divergent aspects may be related to the federal induction process and the characteristics of Brazilian federalism. Although the central government plays a regulatory role and defines incentives for inspection by subnational entities of the country's guidelines, the regionalization process is affected by the context, behavior, technical capacity and political options of the regional actors who are autonomous for the decision and organization of their respective territories.
Keywords:
Public policies; Integration; Oral Health; Disabled people
Resumo
Objetivou-se descrever a extensão da integração sistêmica da assistência odontológica na Rede de Cuidados à Pessoa com Deficiência (RCPD), em seis regiões de saúde brasileiras. Estudo de caso múltiplo, com análise documental e entrevista com atores-chave, entre 2019 e 2021. As categorias analisadas foram: financiamento, cobertura potencial dos serviços de saúde bucal, coordenação do cuidado da atenção primária, avaliação/monitoramento, integração com a rede pública, integração com a rede privada e filantrópica, sistema de informação e governança. Todas as regiões apresentaram serviços de saúde bucal estruturados nos três níveis assistenciais e a extensão da integração sistêmica apresentou características distintas entre as regiões. Os aspectos congruentes e divergentes encontrados podem estar relacionados ao processo de indução federal e às características do federalismo brasileiro. Ainda que o governo central exerça papel regulador e defina incentivos de alinhamento dos entes subnacionais às diretrizes do país, o processo de regionalização é afetado pelo contexto, comportamento, capacidade técnica e opções políticas dos atores regionais que são autônomos para a decisão e a organização dos seus respectivos territórios.
Palavras-chave:
Políticas públicas; Integração; Saúde Bucal; Pessoas com deficiência
Introduction
The organization of health systems can vary from complete fragmentation to full integration of their components, with various arrangements between the two extremes impacting the characteristics of the healthcare models adopted. Due to more effective communication and standardized protocols, integrated health systems are considered to have superior performance in terms of quality and safety. However, these outcomes have not been fully demonstrated (Suter et al., 2009).
Despite the growing enthusiasm for integration, information on its implementation and related initiatives is scattered and hard to access. Although evidence-informed decision-making is required in health policy management, decision-makers have little guidance on planning and implementing integrated healthcare systems to provide adequate services (Suter et al., 2009).
In Brazil, to improve the political and institutional dynamics of the Unified Health System (SUS) and overcome healthcare fragmentation, the Ministry of Health established guidelines aimed at the systemic integration of services through the Healthcare Networks (RAS) (Landim; Guimarães; Pereira, 2019), including the Care Network for People with Disabilities (RCPD).
The RCPD was established in 2012 to expand access, qualify and diversify care strategies for people with physical, hearing, intellectual, visual or multiple disabilities (PwD), effectively articulating the different care points (Brasil, 2012a). Articulation with the oral health policy was established, from the perspective of integrality, based on the guarantee of dental care at the primary level, with the Family Health Units (USF), and specialized, through the Dental Specialty Centers (CEO, in Portuguese). On the hospital level, expanding access to emergency dental care and care under sedation or general anesthesia stands out, adapting surgical centers and teams for this purpose (Brasil, 2019). However, ensuring the right to dental treatment and comprehensive care is not a simple task and requires a virtuous articulation between the different care points in the RCPD (Carneiro; Bousquat; Frazão, 2022).
Studies that relate integrated dental care to the RCPD are scarce. Some studies describe and map specialized dental care for PwD (Condessa et al., 2020; Maciel et al., 2020) and deal with accessibility to public dental services (Rocha; Saintrain; Vieira-Meyer, 2015). Integration and regionalization are SUS guidelines that require efficient mechanisms for regulating and coordinating services and care with a focus on the user (Viana et al., 2017). Scientific knowledge about the extent of systemic integration is key to formulating strategies articulating RASs and can help understand the current impasses for organizing services with different technological densities in a region, including collaboration between healthcare points that make up the line of care. Thus, this study aims to describe the extent of systemic integration of dental care in RCPD in six Brazilian health regions.
Methods
A multiple case study (Yin, 2001) was conducted, covering six Brazilian health regions, with distinct socioeconomic characteristics and service provision, as reported in a previous study (Viana et al., 2017). The regions were intentionally selected and had specialized rehabilitation centers (CERs), CEOs, municipal and/or philanthropic services specializing in rehabilitation actions (Association of Parents and Friends of the Exceptional, Association for Assistance to Disabled Children, non-governmental organizations), and workforce education and training institutions (universities and medical and/or multidisciplinary residency courses). This work is the result of a broader study entitled “Challenges of implementing the Care Network for people with disabilities in different regional contexts: a multidimensional and multiscale approach”1 (MS-SCTIE-Decit/CNPq no. 442801/2018-1), approved by the Research Ethics Committee of the School of Public Health, University of São Paulo, no. 3,441,243.
The selected regions were: Baixada Cuiabana, Entorno Manaus and Alto Rio Negro, Grande Florianópolis, Salvador, São José do Rio Preto and Freguesia do Ó/Brasilândia, hereinafter referred to as A, B, C, D, E and F, respectively.
Data collection took place between July 2019 and September 2021, through interviews with key actors (service managers, oral health professionals, oral healthcare coordination, and social control) in the organization of the RCPD in the oral health area (RCPD-SB), as well as document research of minutes of collegiate meetings and normative instruments that guided the RCPD and the National Oral Health Policy. Semi-structured scripts and questionnaires addressing characteristics of the RCPD policy, organization and structure were used.
Chart 1 presents the main characteristics of the selected regions, based on socioeconomic indicators and service provision. The official sources were the websites of the Brazilian Institute of Geography and Statistics (IBGE), the SUS Information Technology Department (DataSUS), the National Registry of Health Establishments (CNES), the São Paulo Municipal Health Secretariat, and the Ministry of Health (Program for Improving Access and Quality - PMAQ-CEO). The number of municipalities that made up the regions ranged from 10 to 22, except for region F, which was part of a regional health coordination office in the most populous municipality in the country (São Paulo). The population of the regions ranged from 419,142 to 3,167,626 inhabitants and the population density was between 5.75 and 13,306 inhabitants/km². The Gross Domestic Product (GDP) in 2013 ranged from 19 to 29 thousand reais; the percentage of people with per capita family income of less than R$255 in 2010 ranged from 1.1% to 38.9%; the illiteracy rate among those aged 15 or over in 2010 ranged from 1.6% to 6.3% and infant mortality ranged from 8.5 to 24.2 deaths per thousand live births. The provision of health services also varied significantly between regions (Chart 1).
Data on the modality and adherence of CEOs to the RCPD were obtained through the public report on the Ministry of Health website, to analyze the characteristics of the services in the regions. The number of dentists registered to care for PwD and the total weekly hours were obtained for each CEO for December 2019 in each region using the CNES. Indicators related to the supply of professionals per million inhabitants and the total number of weekly hours dedicated to caring for PwD per million inhabitants in each region were calculated. Information regarding adherence to the PMAQ-CEO was also extracted, in addition to information regarding the structure of the oral health network offered in the study territories, by level of care, between 2019 and 2021. The results of the characteristics of the oral health network by health region are shown in Chart 2.
The interviews referred to the structure of the RCPD and the integration of its services with the public and private/private-philanthropic network, the governance structure, explaining the role of the different actors in the organization and decisions involving the implementation of the RCPD, the role of the information system in the systemic integration of the RCPD and the importance of monitoring/evaluation, as well as its periodicity, in the services that made up the RCPD.
Systemic integration is characterized by a set of aspects that allow mapping the level of integration of the RAS, as described in a previous study (Suter et al., 2009), namely: shared financing between entities, coverage and coordination of care focused on Primary Health Care (PHC), monitoring/evaluation, integration of the public network, information system and governance structure of the RCPD-SB. This integration should be understood as a logic of interaction between the services of the health network (public, private, philanthropic), from an equitable perspective (Viana et al., 2017).
In discussing the results, we sought to highlight the similarities and differences between the cases, based on scientific information produced by studies on the regionalization process in Brazil. These processes are affected by the context, behavior, and political choices of regional and local actors, and federal induction mechanisms to mitigate health inequalities in the national territory (Menicucci, 2019). Despite the different theoretical-methodological approaches and various objectives of these studies, the information was used to raise possible explanatory hypotheses linked to the results.2
Results
As mentioned in Chart 1, all the health regions studied had health services structured at the three levels of care, with a predominance of a preferential entry point through PHC. However, the potential coverage, offered by both PHC and specialized services, varied considerably by region, showing significant structural heterogeneity.
Regarding the oral health network (Chart 2), the number of CEOs ranged from 1 to 8, depending on the region, with types 2 and 3 being the most frequent (17 services each) and type 1 the least frequent (5), out of a total of 39 CEOs. The CEOs differ in the number of dental chairs: 3 (CEO type 1), 4 to 6 (CEO type 2) and 7 or more (CEO type 3). The indicator that measures the availability of CEOs adhering to the RCPD ranged from 2.4 (region F) to 9.2 (region A) CEOs for every million inhabitants. The total number of professionals accredited in the CEOs to provide care to PwD ranged from 1 to 24, meaning that the availability of these professionals was more than 10 times greater in region C compared to F. Regarding the weekly hours dedicated to providing care to PwD in the CEOs, values ranged from 0.05 to 0.46 hours per thousand inhabitants. Adherence to the PMAQ-CEO was above 80% in all research regions, except in region A, where adherence was 75%. Regarding the structure of the regions, all presented dental care services for PwD included in the three levels of care, in addition to the emergency and urgency network and, depending on the region, there were partnerships with the private/private-philanthropic sector and higher education institutions.
Chart 3 shows the extent of systemic integration according to the categories: shared financing among entities; coverage and coordination of user-centered care by the PHC; monitoring/evaluation; integration with the private and/or philanthropic network; integration with the public network; information system and governance structure in the RCPD-SB corresponding to each health region.
The funding shared between the entities had more similarities than differences. In all regions, the public dental services linked to the RCPD were maintained through resources from the state and/or municipal budget, in addition to federal incentives provided for the monthly costs of the CEOs (Brasil, 2012b). One of the regions had a mechanism to receive specific donations from individuals/legal entities made through the State Health Fund (region A). Other federal incentives were related to voluntary adherence to the RCPD (regions C, E and F), or for good performance in the PMAQ-CEO (region E). Some regions benefited from specific state programs that supported municipalities in providing services (regions C, E and F).
Regions with federal, state and municipal funding sources (C, D, E and F especially) had PHC coverage equal to or greater than 40%. In regions A and B, coverage was low (less than 40%). According to the interviewees, in half of the cases investigated, care coordination was centered on PHC.
Data on the use of information systems showed that half of the regions (C, E and F) used integrated electronic medical records accessible to all professionals. In region B, some services did not have sufficient technological resources to use electronic medical records. Two regions had electronic medical records not integrated with the RCPD (B and D), and no information was found for region A in this regard. In regions C, E and F, appointments for specialized care were scheduled via the regulatory system.
Monitoring/evaluation was occasional in regions A, B and D, restricted to the occurrence of the PMAQ-CEO or according to ministerial guidelines. In the other regions it occurred periodically, every six months (region C), bimonthly (region F) or monthly (region E). In region A, one of the specialized services had its own monitoring instrument, but it was not standard for RCPD-SB and was not being used. In region C, the CEOs had productivity indicators monitored to ensure compliance with targets established by the state administration, which were considered weak. In region E, their own indicators, created by the CEO's management, were used in addition to those monitored by the Ministry of Health.
Qualifying care depends on how services communicate and interact to integrate health promotion, prevention, and rehabilitation actions, as well as the ability to incorporate information and communication technologies (information systems) to advance this integration. Thus, integration with the private and/or philanthropic network was occasional or informal in all regions, except in B, where it was regular and formal, with public dental care for PwD offered by philanthropic institutions through a formal agreement (the municipality provided the professionals and purchased the supplies). Regarding integration with the public network, this occurred, in all regions, between the USF and the CEOs. It was observed that region C had a CEO created by the Federal University of Santa Catarina (UFSC) that acted as an important link in assisting the municipalities in the region that did not have specialized dental services, and in region F, there were different employment relationships between the professionals who occupied the same space (direct administration and contract through a social health organization).
The interaction between the actors that make up this complex structure of the RCPD reflects the governance capacity to mobilize efforts around the functioning and qualification of the care offered to PwD. Thus, the governance structure of the RCPD-SB was classified as restricted (when it was limited only to oral health professionals), intermediate (included other professional areas, but without social/citizen participation) or broad (included social/citizen participation). Regions D and E showed characteristics of restricted governance; regions A and B, intermediate governance; and regions C and F, broad governance.
Discussion
A multiple case study was conducted to analyze the extent of systemic integration of dental care in the RCPD, in different health regions of the country. Regions C, E and F presented characteristics compatible with a more extensive systemic integration involving most of the aspects analyzed: financing, potential ESB coverage and level of coordination of PHC care, monitoring/evaluation, integration with the public network and support from the health information system, and broad governance structure. Of these regions, only E presented a restricted governance structure. Regarding integration with the private and/or philanthropic network, only in region B indications of formalized relationships and cooperation commitments between services were found.
Similar aspects of the systemic integration of the RCPD concerning service modalities, the supply of professionals and forms of financing, observed in the different regions, can be explained by the characteristics of federalism and the legal-normative structure that governs the Brazilian health system, such as the structure of the RCPD-SB, illustrated in Chart 2. The federal government, through the Ministry of Health, is responsible for financing and formulating the national health policy, and for conducting the process of agreement with subnational governments for decision-making in this sectoral policy. The similarities in the health regions express, to a certain extent, the process of implementation of the RCPD in the country, in which the design of the public policy and the mechanisms of federal induction were deliberated in the different spaces of agreement of the health system corresponding to the national, state and regional levels (Szwako; Lavalle, 2019). Despite this process, the provision of services was uneven. Although the central government plays a regulatory role and defines incentives for subnational entities to align with the country's guidelines, regionalization is affected by the context, behavior, technical capacity, and political options of regional actors (Menicucci, 2019), who are autonomous to decide and organize their territories. These aspects affect the participation of municipalities and the coordinating role of states in configuring the RAS. The result may be manifested in differences in the capacity to produce services in each region, compatible with the discrepancies in the structure available for assistance to PwD and the general population in the investigated regions (Chart 2).
Health management in Brazil is decentralized, that is, subnational entities represented by states, municipalities, and the Federal District are endowed with administrative, financial, and political autonomy to organize health services in their territory, under the guidance of constitutional guidelines. The role of formulating and coordinating this policy at the national level lies with the Ministry of Health, which acts as the national manager of the system (Costa; Neves, 2013). The uniqueness of the Brazilian federative model lies in the greater horizontality of relationships, which require coordinated actions (Martinelli; Viana; Scatena, 2015), which partly explains the structural similarity found in PHC services in the regions analyzed. However, if dialogue and relationships between entities are not well established, intergovernmental conflicts, competition, divergent interests and predatory behavior may occur (Martinelli; Viana; Scatena, 2015).
A study in region D showed that disputes between the state and the hub municipality regarding specialized and hospital health services were common, given the technical and political differences of their managers. In region A, research showed that the State Health Secretariat (SES), by failing to fulfill its shared responsibilities in the Management Commitment Agreement (TCG), wore down horizontal relationships, interfered in the regionalization process, failed to strengthen municipal management competencies, and was not able to reduce health inequalities (Martinelli; Viana; Scatena, 2015).
Although PHC is a municipal responsibility, federal resources are the main financial incentives guiding its implementation and monthly costs. This factor explains part of the similar results found in the different health regions regarding the organization of services, such as the presence of USF or primary care units with oral health teams. However, the potential population coverage of oral health services by PHC varied considerably, being below 40% in regions A and B, which had difficulties in coordinating care. Although region D has 40.43% coverage in PHC, it also had difficulties in coordinating care. PHC is not a preferential gateway to the health system and may be an overload for other services and disrupt access flows, resulting in discontinuity and fragmentation of care (Almeida et al., 2016).
PHC is fundamental in structuring the RAS, requiring a solid regional arrangement to exercise its role as care coordinator (Bousquat et al., 2017). A study conducted in region F demonstrated that oral health services were integrated with other health services, with well-established attributions for each level of care, contributing to the coordination of care in the region (Carneiro; Bousquat; Frazão, 2022). Studies in region B and in the state of region D identified the lack of knowledge of municipal managers about the dynamics and situation of PHC in a regional context, compromising the management of the RAS at a level capable of responding to the demands of the population (Almeida et al., 2016; Garnelo; Sousa; Silva, 2017).
Failures in the coordination of care in the RAS are generally manifested by problems of accountability and lack of dialogue between services, resulting in fragmentation of care (Mendes, 2011). Electronic medical records favor interprofessional communication and information management between different health services, an essential condition for the quality of care (Tsai et al., 2020). The regions analyzed showed differences in the availability of technological resources and information systems, with a positive highlight for regions C, E and F, where electronic medical records were integrated with the PHC units and CEOs. These differences in the implementation of health information systems show their heterogeneity, conditioned by different organizational arrangements and influenced by the characteristics of Brazilian municipalities/regions (Cielo et al., 2022).
The incorporation (or not) of monitoring/evaluation processes can attest to how public dental services linked to the RCPD have advanced in qualification. In regions A, B, and D, monitoring/evaluation was sporadic, tied to the PMAQ-CEO period or according to guidelines from the Ministry of Health. Studies have documented shortcomings in this aspect. In region A, the absence of specific monitoring/evaluation actions was identified (Carneiro; Bousquat; Frazão, 2022). In region B, there were no monitoring/evaluation actions according to the workforce interviewed (Garnelo; Sousa; Silva, 2017). In region D, researchers reported a lack of monitoring of services provided by CEOs, favoring non-compliance with minimum targets for specialized dental care production for PwD, established by the Ministry of Health (Chequer; Santos, 2021).
In the other regions of the study, the result was positive concerning monitoring/evaluation, with defined frequency. A study conducted in region E highlighted this dimension as part of the institutional culture of services, using a specific instrument, the result of which was a monitoring panel, besides the evaluation of the whole health network (Carneiro; Bousquat; Frazão, 2022).
The Brazilian healthcare system is made up of a complex network of service providers that in general compete. It is made up of three subsectors: the public (services financed and provided by the State), the private for-profit or non-profit (services supported in several ways by public and/or private resources) and the supplementary, composed of the different private health care plans and insurance policies, encouraged by tax subsidies (Paim et al., 2011). These public-private relations involve various disputes related to the distribution of existing resources and obligations and counterparties, contributing to the maintenance of the bottleneck of underfunding in health, even in more progressive governments, by not including this structural problem in the political agenda (Abers; Almeida, 2019).
These arrangements between the public and private sectors have been in place in several European countries for over half a century, where the State and the private sector coexist in healthcare provision. The intensity of the combination varies between countries and over time, influenced by the characteristics of society and the social protection model. The challenge is to find the most appropriate combination considering current transformations (Santos; Santos; Borges, 2013). In the regions investigated, except for region B, the integration relationships between public providers, and between them and private and philanthropic providers, were occasional and informal, hindering the mobilization of a broader set of resources that would enable a complete cycle of oral health care for PwD. A study carried out in regions A and E described the implementation of the RCPD in the scope of oral health, showing that no partnerships were found between public and private and philanthropic providers concerning dental care for PwD (Carneiro; Bousquat; Frazão, 2022).
In this study, integration between the services of the PHC network was more intense than between these and specialized services. Region F presented the particularity of having two distinct models for managing health professionals: a public model managing specialized care and a model through private non-profit organizations managing the PHC network. In region C, integration was observed between public services and a training entity that, according to a previous study (Mello et al., 2014), played a central role in building the care network in the region, offering basic and specialized dental services. Several initiatives have been developed worldwide to experiment with new managerial forms and PHC services provision. In Western Europe, two strategies have been mainly used: competition between public providers for the so-called “public market” and the privatization of PHC with measures such as the progressive replacement of public financing by private financing, based on initiatives such as co-payment for the use of services and the privatization of several PHC service providers (Carneiro Júnior; Nascimento; Costa, 2011). In Brazil, the state of São Paulo, where region F is located, was one of the first to outsource the administration of health services through non-profit organizations (Pilotto; Junqueira, 2017).
All study regions mentioned the presence of state incentives, to a greater or lesser extent; however, the governance structure displayed distinct characteristics. Only regions C and F had characteristics of broad governance, with a greater multiplicity of actors in the process of agreement and decision-making around the regional RCPD configuration. The presence of a few actors in the coordination and mediation of relations for the integration of the RCPD corroborates the notion that the strategy of creating aggregated regional management boards, to more clearly establish the responsibilities of each federate entity to reduce competing competences, has not been sufficient to expand governance (Menicucci, 2019). Previous studies carried out in region C have identified the Regional Inter-managerial Commission (CIR) and the Bipartite Inter-managerial Commission (CIB) as consolidated governance spaces, with the capacity to develop and implement policies, despite the regionalized oral health network being positioned peripherally to the other RAS (Mello et al., 2014; Godoi; Mello; Caetano, 2014; Godoi et al., 2020). Citizen participation can favor the integration of different actors involved in the care of PwD, by bringing together, in addition to users, universities, managers and health professionals, as happened in region F, with the consolidation of the Rehabilitation Forum, created in 2012 (Rosa et al., 2016; Haberland et al., 2017). In this sense, introducing steering groups (GC) tends to favor the multiplicity of actors to establish cooperative governance.
Only region A mentioned the presence of oral health in the GC, which was undergoing restructuring, placing it in an intermediate governance classification. Region A belongs to a subnational unit that was a pioneer in regionalization (1995-2002), but, from 2003 onwards, management changes diverted the regionalization process from its previous course, aimed at reducing inequalities and strengthening management capacities at the local level (Martinelli; Viana; Scatena, 2015).
Governance in region B was also classified as intermediate, as it had multiple institutional actors, but without citizen participation. The subnational unit to which this region belongs was the last to join the Pact for Health, and remained with an incipient institutionality, often favoring the fragmentation of services. SES’s leading role in organizing the RAS has focused more on actions aimed at the municipal level, which has been detrimental to collective and supportive construction among federated entities (Garnelo; Sousa; Silva, 2017). Furthermore, the discontinuity in management processes and high turnover of managers seems to have an impact on the functioning of collegiate spaces (CIR, CIB), which have focused more on resolving doubts in the management of the tools for recording activities prescribed by the federal level than on promoting negotiations to strengthen relations between public and private entities and the shared financing of action initiatives from a regional perspective (Garnelo; Sousa; Silva, 2017).
The complexity of governance in integrated health systems requires mechanisms for accountability and decision-making, with structures capable of promoting integration, ensuring the representation of various stakeholders in delivering continuous health care (Suter et al., 2009). In regions D and E, governance was assessed as restricted, with only oral health professionals participating. A study in region D state suggested that managers were unaware of how PHC works and its possibilities for coordinating regionalized care, with statements systematically restricted to the municipal context (Almeida et al., 2016). In the governance in oral health services, it was suggested that there are difficulties in coordinating inter-municipal actions and the absence of a state government agenda to promote regional CEO arrangements (Chequer; Santos, 2021).
Regarding the limitations of this study, although interviews were conducted to represent the multiplicity of key actors in the collegiate spaces in the different regions, and the minutes of deliberative collegiate bodies were examined in detail, the availability of more resources would allow other elements of regional realities to be observed, to complement the findings. Interviews with PwD, in each context, could aggregate a greater variety of data on the extent of systemic integration. In addition, aspects related to the actions of GC aimed at oral health care for PwD were not widely explored in this study and could contribute to future research. Another limitation concerns the case study method, which makes it impossible to extrapolate the results to other territories. However, it allows the verification of propositions (Yin, 2001) that can help explain aspects that make up systemic integration in the organization of care networks in health systems in other territories.
During the systemic integration analysis process, some regions presented well-established partnerships with the private and philanthropic sectors that could be better explored, especially in the management modality format, since these arrangements have been expanding in the organization of the SUS (as was the case observed in region F), especially in PHC.
All health regions studied had health services structured in the three levels of care, with a predominance of preferential entry points through PHC. However, the potential coverage, offered by both PHC and specialized services, varied greatly by region, showing significant structural heterogeneity. The structure of the oral health service network is unequal between regions. The difference in the provision of specialized professionals for PwD care was ten times greater between regions. Systemic integration showed varied extent in the regions. Three of them had high integration levels in the categories related to financing, potential ESB coverage and level of coordination of PHC care, monitoring/evaluation, integration with the public network and support from the health information system, and broad governance structure (the latter aspect is restricted to region E). Integration with the private and philanthropic network was narrow in only one region. These congruent and divergent aspects may be related to the federal induction process and the characteristics of Brazilian federalism.
Although the central government plays a regulatory role and defines incentives for aligning subnational entities with the country's guidelines, the regionalization process is affected by the context, behavior, technical capacity and political options of regional actors who are autonomous in the decision-making and organization of their respective territories.
Acknowedgements
This study was carried out with the support of the Coordination for the Improvement of Higher Education Personnel - Brazil (CAPES) - Financing Code 001.
References
- ABERS, R. N.; ALMEIDA, D. R. Participação no século XXI: o embate entre projetos políticos nas instituições participativas federais. In: ARRETCHE, M.; MARQUES, E.; FARIA, C. A. P. (org.). As políticas da política: desigualdades e inclusão nos governos do PSDB e do PT. São Paulo: Editora UNESP, 2019.
- ALMEIDA, P. F. et al. Integração assistencial em região de saúde: paradoxo entre necessidades regionais e interesses locais. Saúde Soc., v. 25, n. 2, p. 320-335, 2016.
- BOUSQUAT, A. et al. Atenção primária à saúde e coordenação do cuidado nas regiões de saúde: perspectiva de gestores e usuários. Ciênc. Saúde Colet., v. 22, n. 4, p. 1141-1154, 2017.
- BRASIL. Ministério da Saúde. Guia de Atenção à Saúde Bucal da Pessoa com Deficiência. Brasília: Ministério da Saúde, 2019.
- BRASIL. Ministério da Saúde. Portaria nº 793, de 24 de abril de 2012. Institui a Rede de Cuidados à Pessoa com Deficiência no âmbito do Sistema Único de Saúde. Diário Oficial da União, Brasília, DF, 25 abr. 2012a.
- BRASIL. Ministério da Saúde. Portaria nº 1.341/GM, de 13 de junho de 2012. Define os valores dos incentivos de implantação e de custeio mensal dos Centros de Especialidades Odontológicas - CEO. Diário Oficial da União, Brasília, DF, Seção 1, n. 126, 2 jul. 2012b. p. 74.
-
CARNEIRO, J. D. B.; BOUSQUAT, A.; FRAZÃO, P. A Implementação da Rede de Cuidados à Pessoa com Deficiência no Âmbito da Saúde Bucal a partir do Modelo da Coalizão de Defesa em Duas Regiões de Saúde no Brasil. Administração Pública e Gestão Social, v. 14, n. 2, 2022. DOI: https://doi.org/10.21118/apgs.v14i2.12731
» https://doi.org/10.21118/apgs.v14i2.12731 - CARNEIRO JÚNIOR, N.; NASCIMENTO, V. B.; COSTA, I. M. C. Relação entre Público e Privado na Atenção Primária à Saúde: considerações preliminares. Saúde e Sociedade, v. 20, n. 4, p. 971-979, 2011.
- CHEQUER, T. P. R.; SANTOS, A. M. Organização de Centros de Especialidades Odontológicas numa Região de Saúde na Bahia. Physis: Revista de Saúde Coletiva, v. 31, n. 3, e310324, 2021.
-
CIELO, A. C. et al. Implementation of the e-SUS Primary Care Strategy: an analysis based on official data. Revista de Saúde Pública, v. 56, n. 5, 2022. DOI: https://doi.org/10.11606/s1518-8787.2022056003405
» https://doi.org/10.11606/s1518-8787.2022056003405 - CONDESSA, A. M. et al. Atenção odontológica especializada para pessoas com deficiência no Brasil: perfil dos centros de especialidades odontológicas, 2014. Epidemiol. Serv. Saúde, v. 29, n. 5, p. 1-11, 2020.
- COSTA, L. A.; NEVES, J. A. B. Burocracia e inserção social: um estudo sobre o Ministério da Saúde na gestão do Sistema Único de Saúde. Saúde Soc., v. 22, n. 4, p. 1117-1131, 2013.
- GARNELO, L.; SOUSA, M. B. L.; SILVA, C. O. Regionalização em Saúde no Amazonas: avanços e desafios. Ciênc. Saúde Colet., v. 22, n. 4, p. 1225-1234, 2017.
- GODOI, H. et al. Óbices da governança pública e sua influência sobre a atenção à saúde bucal no Estado de Santa Catarina, Brasil. Cadernos de Saúde Pública, v. 36, n. 11, e00184719, 2020.
- GODOI, H.; MELLO, A. L. S. F.; CAETANO, J. C. Rede de atenção à saúde bucal: organização em municípios de grande porte de Santa Catarina, Brasil. Cadernos de Saúde Pública, v. 30, n. 2, p. 318-332, 2014.
- HABERLAND, R. et al. O fazer coletivo nas políticas de saúde da FÓ/Brasilândia (SP): fóruns, redes, grupalidades. Distúrbios da Comunicação, v. 29, n. 4, p. 793-808, 2017.
- LANDIM, E. L. A.; GUIMARÃES, M. C. L.; PEREIRA, A. P. C. Rede de Atenção à Saúde: integração sistêmica sob a perspectiva da macrorregião. Saúde Debate, v. 43, n. 5, p. 161-173, 2019.
- MACIEL, F. J. et al. Análise espacial da atenção especializada na Rede de Cuidados à Pessoa com Deficiência: o caso de Minas Gerais. CoDAS, v. 32, n. 3, e20180104, 2020.
- MARTINELLI, N. L.; VIANA, A. L. D’Á.; SCATENA, J. H. G. O Pacto pela Saúde e o processo de regionalização no estado de Mato Grosso. Saúde Debate, v. 39, n. especial, p. 76-90, 2015.
- MELLO, A. L. S. F. et al. Saúde bucal na rede de atenção e processo de regionalização. Ciência & Saúde Coletiva, v. 19, n. 1, p. 205-214, 2014.
- MENDES, E. V. As Redes de Atenção à Saúde. Brasília: Organização Pan-Americana da Saúde, 2011.
- MENICUCCI, T. Política de saúde no Brasil: continuidades e inovações. In: ARRETCHE, M.; MARQUES, E.; FARIA, C. A. P. (org.). As políticas da política: desigualdades e inclusão nos governos do PSDB e do PT. São Paulo: Editora UNESP, 2019.
-
PAIM, J. et al. O sistema de saúde brasileiro: história, avanços e desafios. The Lancet, v. 377, n. 9779, p. 1778-1797, 2011. DOI: https://doi.org/10.1016/S0140-6736(11)60054-8
» https://doi.org/10.1016/S0140-6736(11)60054-8 - PILOTTO, B. S.; JUNQUEIRA, V. Organizações Sociais do setor de saúde no estado de São Paulo. Serviço Social & Sociedade, n. 130, p. 547-563, 2017.
-
ROCHA, L. L.; SAINTRAIN, M. V. L.; VIEIRA-MEYER, P. G. F. Access to dental public services by disabled persons. BMC Oral Health, v. 15, n. 35, 2015. DOI: 10.1186/s12903-015-0022-x.
» https://doi.org/10.1186/s12903-015-0022-x. -
ROSA, E. Z. et al. Desafios da gestão do cuidado em rede: uma análise dos casos de saúde mental na Atenção Básica. In: VICENTIN, M. C. G. et al. (org.). Saúde mental, reabilitação e atenção básica: encontro entre universidade e serviços de saúde. São Paulo: 2016. p. 83-99. Disponível em: https://www.pucsp.br/prosaude/downloads/publicacoes/saude_mental_reabilitacao_e_atencao_basica-parte-2.pdf Acesso em: 9 mar. 2024.
» https://www.pucsp.br/prosaude/downloads/publicacoes/saude_mental_reabilitacao_e_atencao_basica-parte-2.pdf - SANTOS, I. S.; SANTOS, M. A. B.; BORGES, D. C. L. Mix público-privado no sistema brasileiro: realidade e futuro do SUS. In: FUNDAÇÃO OSWALDO CRUZ. A saúde no Brasil em 2030: prospecção estratégica do sistema de saúde brasileiro. Rio de Janeiro: Fiocruz/IPEA/Ministério da Saúde/Secretaria de Assuntos Estratégicos da Presidência da República, 2013. v. 4. p. 73-131.
- SUTER, E. et al. Ten Key Principles for Successful Health Systems Integration. Healthc. Q., v. 13, n. esp., p. 16-23, 2009.
- SZWAKO, J.; LAVALLE, A. G. “Seeing like a social movement” - Institucionalização simbólica e capacidades estatais cognitivas. Novos Estud. CEBRAP, v. 38, n. 2, p. 411-434, 2019.
- TSAI, C. H. et al. Effects of Electronic Health Record Implementation and Barriers to Adoption and Use: A Scoping Review and Qualitative Analysis of the Content. Life, v. 10, n. 12, p. 327, 2020.
- VIANA, A. L. D’Á. et al. Região e Redes: abordagem multidimensional e multinível para análise do processo de regionalização da saúde no Brasil. Rev. Bras. Saúde Mater. Infant., n. 17, supl. 1, p. 517-526, 2017.
- YIN, R. K. Estudo de caso: planejamento e métodos. 2. ed. Porto Alegre: Bookman, 2001. 200 p.
All research data are available in this text.
