The process of building up regional health management in the State of São Paulo: subsidies for analysis 1 - PDF

The process of building up regional health management in the State of São Paulo: subsidies for analysis 1 O processo de construção da gestão regional da saúde no estado de São Paulo: subsídios para a análise

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The process of building up regional health management in the State of São Paulo: subsidies for analysis 1 O processo de construção da gestão regional da saúde no estado de São Paulo: subsídios para a análise Áquilas Mendes Pontifícia Universidade Católica. Departamento de Economia. São Marília C. P. Louvison Aurea M. Z. Ianni Marcel Guedes Leite Pontifícia Universidade Católica. Departamento de Economia. São Laura C. M. Feuerwerker Oswaldo Y. Tanaka Ligia Duarte José Alexandre Buso Weiller Natália Carolina Cairo Lara Pontifícia Universidade Católica. Programa de Pós-graduação em Economia Política. São Lygia de Andrade Machado Botelho Pontifícia Universidade Católica. Programa de Pós-graduação em Economia Política. São Cristiane A. L. Almeida Correspondence Áquilas Mendes Faculdade de Saúde Pública da USP Av. Dr. Arnaldo, 715, Cerqueira Cesar. São Paulo, SP, Brazil. CEP This article presents the results of the research Analyzing the Process of Constructing regional Management in the State of São Paulo COAP/Health Care Networks, 2013, by professors and their students following the research line of Politics, Management and Health in the Postgraduate Program in Public Health of the USP, financed by the Pan American Health Organization (Opas) Pact BR/ LOA/ DOI /S Saúde Soc. São Paulo, v.24, n.2, p , Abstract This article presents the main results of the survey on the regional management building process in the State of São Paulo, during the discussion of the COAP / Care Networks, in order to provide a basis for understanding this process of regional health pact, focusing on the metropolitan areas of Bauru, Santos, Grande ABC and the Ribeira Valley. In addition to the results presented on the health regions studied, the methodology used in the development of the construction of profiles of the regions is itself a proposal for a methodology of analyzing regional health profiles. The first section presents the general methodology for analyzing health regions. The second part covers the results and discussion of the research, organized into two items. The first refers to the analysis of the profiles of the five São Paulo health regions surveyed. The second item analyzes the main aspects of the process of regional health pact in São Paulo, highlighting strengths and limitations, based on interviews with municipal managers and supporters of the Council of Municipal Health Secretaries of São Paulo in these regions. Keywords: Health Regionalization; Regional Management; Health Care Networks; State of São Paulo. Resumo Este artigo apresenta os resultados gerais da pesquisa sobre o processo de construção da gestão regional no estado de São Paulo, durante a discussão do COAP/redes de atenção, com o intuito de fornecer subsídios para a compreensão deste processo de pactuação regional da saúde, com enfoque nas regiões de saúde de Bauru, Baixada Santista, Grande ABC e Vale do Ribeira, no estado de São Paulo. Além dos resultados apresentados sobre as regiões de saúde estudadas, a metodologia utilizada no desenvolvimento da construção dos perfis das regiões constitui em si uma proposta metodológica de análise de perfis regionais de saúde. A primeira parte do artigo apresenta a metodologia geral adotada para a análise das regiões de saúde; a segunda, abrange os resultados e a discussão da pesquisa, organizados em dois itens. O primeiro destes itens refere-se à análise dos perfis das cinco regiões de saúde pesquisadas no Estado. O segundo, analisa os principais aspectos do processo de pactuação regional da saúde em São Paulo, destacando potencialidades e limites, a partir de entrevistas realizadas com gestores municipais e apoiadores do Conselho de Secretários Municipais de Saúde de São Paulo dessas regiões. Palavras-chave: Regionalização da Saúde; Gestão Regional; Redes de Atenção à Saúde; Estado de São Paulo. 424 Saúde Soc. São Paulo, v.24, n.2, p , 2015 Introduction The Unified Health System regionalization process was once again placed on the political agenda of its management in 2006 with the Pact for Health, a perspective of locoregional links in the national and inter-state pact. It took on a faster pace in Brazil with the publication of Presidential Decree No of July 28, 2011, in which the Organizational Contract of Public and Health Action (COAP) and the policy of the Health Care Networks (Brazil, 2011) were established. The process of discussing the COAP in the States has been going on since the second half of 2012 and intensified from 2013 onwards, with particulars for each federal unit. In the state of São Paulo, through the municipalities and the Ministry of Health (SES/ SP), the discussion on drawing up the COAP was very active and municipal and state managers have made great efforts to organize, provide and analyze the list of indicators addressed in Decree No. 7,508. In addition to the 101 COAP monitoring indicators, this decree guides the construction of the health map, which describes the distribution of human resources and actions and health services provided by the NHS and the private sector geographically, considering the capacity installed, investments and performance measured from the system health indicators. Certain authors in the field of public health argue that in order for decentralization in health to play an organizational role the relationship with the health regionalization process becomes important (Ferreira, 2011; Lavras, 2011). Ferreira (2011), in particular, understands that regionalization should be understood as a process of organizing health actions and services in a region in order to ensure comprehensive care, the rationality of expenses and optimization of resources and equity, with a view to guaranteeing the right to health. Still, this author adds that regionalization should be understood as a management tool in the health system organization, used to ensure an efficient allocation of health care. It is well-known that regionalizing the SUS, as a health decentralization policy, was included in the Basic Operational Norms (BON), mainly BON 93 and BON 96, and the Health Care Operational Norm (Hcon), imposing more institutionalization on this process, consolidating itself with the passing of the Health Pact in 2006, intensified by presidential Decree (Brazil, 2006; 2011). This intensification of the regionalization process accentuates conflicts between managers and inter-governmental actors who mostly encounter conflicts between local, regional/state and national identities (Souza, 2001) 2. In the state of São Paulo, in particular, the decentralization of health was also marked by the process of decentralizing the State Department of Health (SES). The starting point for this process was the reform movement from the state government, throughout the Franco Montoro ( ) government. In the last year of this government, SES / SP activity management was decentralized with the creation of 62 Regional Health Offices (Ersas), 47 in the interior and 15 in the metropolitan area. In the organizational dimension, the restructuring of the SES followed the principles of regionalizing and decentralizing services and basic health care (Mendes, 2005) 3. Strictly speaking, São Paulo State participated in moments of centralization and decentralization leading up to the creation of the SUS. The role of state management in health services is considered of importance in coordinating municipal action plans and providing them with technical support. However, there is known to be a gap persisting in the state of São Paulo, to the extent that the state manager has not been presented as an effective coordinator of the state regionalization process, since the creation of the SUS (Mendes, 2005). In general, the importance that the territorial dimension has taken in the process of regionalizing health policy is highlighted. The distribution of resources for health care that seeks to rationalize the actions and services provided to all citizens needs to be the object of the pact between the federal agencies, particularly the municipalities that make up the health regions. It is after all, through these 2 For a discussion of the challenges of health regionalization in the context of the country s metropolitan areas, specifically the Baixada Santista, see Ianni et al. (2012). 3 For further details of the path followed by the SUS in the State of São Paulo, highlighting the regionalization of the SES/SP, see Mendes (2005), specifically cap.2. Saúde Soc. São Paulo, v.24, n.2, p , that most citizens needs must be met, requiring a minimum number of actions and services. In order to discuss the COAP implementation process in some regions of São Paulo, this article provides information for understanding the regional health pact process in the state, focusing on the health regions of Bauru, Baixada Santista, Greater ABC and Vale do Ribeira, examining their potential and limits. In addition to the results presented on the health regions studied, the methodology used in constructing profiles of the regions is itself a methodology of analyzing regional health profiles, offered as a product of research. The article, then, is organized into two parts. The first presents the general methodology for analyzing health regions. The second covers the results and discussion, structured into two items. The first refers to analyzing the profiles of each of the five São Paulo health regions that were the object of this research - Baixada Santista, Vale do Ribeira, Greater ABC and Bauru. The second item examines the main aspects of the regional pact health process in the state, highlighting strengths and limitations, based on interviews with municipal managers and supporters of the Council of Municipal Health Secretaries of São Paulo (Cosems / SP) of these regions. Methodology for analysis With a view to deepening understanding of the territorial dimension, the indicators proposed by the COAP and others not covered by Decree No. 7,508/2011, used for health map in the primary care pact in the indicators matrix of the State Health Secretariat / SP and Cosems / SP were analyzed. In addition, the indicators suggested by the SUS Monitoring and Management Assessment Panel, proposed by Tamaki et al. (2012), were also used, helping to understand the unique dynamics of each region. Flow indicators were analyzed, related to inter and intra-regional population movement commuting to work or study and for hospitalization -, in order to recognize the consonance between the towns making up a particular health region in relation to inbound and outbound flows of residents in these parts of the territories. The health regions analyzed were those of Baixada Santista, Greater ABC, Vale do Ribeira and Bauru. The criteria for choosing these regions were: tradition of constructing regionalized policies; metropolitan and non-metropolitan characteristics; different geographical locations in the state; peculiarities of socioeconomic conditions in the regions and in their health care networks; and participation in different São Paulo Regional Health Care Networks, recently defined in the regionalization process of the State. It should be noted that the health regions of Baixada Santista and Vale do Ribeira together make up the RRAS 07, while the Greater ABC Health Region has its own care network, RRAS 01, and the Bauru Health Region is part of RRAS 09, along with five other health regions. Analysis of the region profiles is divided into five areas: i) socio-economic and budgetary information; ii) living and health conditions; iii) health surveillance; iv) health care network; and, v) dynamics of inter- and intra-regional population movement (flow analysis). The year 2011 was used for a preliminary survey, identifying the availability and capability of information to compose the desired matrix of regional analysis. The fifth area, in particular, deals with an innovation in regional profile analysis. This is because we sought to incorporate a regional dimension seldom or never dealt with in the health sector. It is an analysis of commuter information provided by the 2010 Census, along with data from the Hospitalization Authorization (AIH). The objective was to understand the dynamics of inter and intra-regional population movement characterizing the health region. Thus, for the purposes of this article, we present analysis of only one region - Baixada Santista - it being considered more important to describe the methodological approach used than to present all the surveyed areas. In a second, qualitative, stage of research, interviews were conducted with managers, municipal secretaries and supporters of Cosems / SP from the areas in question. This stage aimed to follow the COAP discussion process in these regions, in order to aid understanding of the regional health pact process in the state. Eight interviews were conducted with those considered key players in the regional pact process then underway: The Secretary 426 Saúde Soc. São Paulo, v.24, n.2, p , 2015 of Health for Jacupiranga, DRS Vale do Ribeira; the Cosems supporter for Vale do Ribeira; the Cosems supporter for Baixada Santista; Secretary of Health for the municipality of Mauá; Secretary of Health for Bauru, Secretary of Health for Pederneiras and the Cosems supporter for the Bauru region. The qualitative approach involved four aspects of interest to the research project: 1) identifying role and/or leadership in the regional health pact process; 2) the actors understanding of the region / regionalization in the political, technical-operational, financial and installed structure dimensions; 3) attitude toward the COAP; and 4) attitude to care networks, especially the Cegonha and Urgency-Emergency networks. Results and discussion Analyzing the profiles of the five health regions The regional and municipal indicators proposed for the four regions were analyzed and grouped by area studied. Indicators were identified that could compose an analysis matrix that would allow a better and simple way of identifying the regional profile and contribute to monitoring and evaluating regional SUS management. The analysis of regional inequalities, identifying the highest and lowest values that make up the regional mean, gave a view that contributes to this necessity and allows interventions seeking greater regional equity. Area 1: socio-economic and budgetary regional health indicators The Greater ABC is part of the Metropolitan Region of São Paulo (MRSP) and 6.13% of São Paulo s population can be found there, it is well urbanized and densely populated, with a high aging index and high GDP per capita. The metropolitan region of Baixada Santista (RMBS) is located on the coast of the state, and is quite urbanized with a high proportion of seniors and low sewage rate (Table 1). In 2011, the RMBS spent R $ per capita on health, with 27.51% of this total from SUS transfer, and spending of own resources on health reached 22.28%. The region of Bauru is located in the interior of the state; it contains 1.45% of the population and 3.45% of the state area, with population density far below the state average, a high rate of urbanization and higher than average access to sewer network compared to the rest of the state. The region of Vale do Ribeira, which includes the cities on the south coast of São Paulo state, contains about 0.66% of the population and 5.35% of the state area, with population density far below the state average, and sewage system average that is lower than the average for São Paulo state and a high illiteracy rate (Table 1). With regards the budgetary health indicators, the state of São Paulo, excluding the state capital, spends R$ per inhabitant on health, of which 27.13% is from SUS transfer, corresponding R$ per inhabitant/year. Own spending on health was R$ per capita, whereas the available state revenues (taxes and constitutional transfers) were R$ 1.565,90. Thus, health spending in the state of São Paulo reached 23.11% of own resources (EC 29 link), as seen in Table 1. The region with the highest per capita spending of own resources is that of Baixada Santista (R$ ). At the same time, it has the lowest per capita revenue available (taxes and constitutional transfers), compared with the other health regions (R$ 1,731.52). This means that this region commits 29.1% of overall available revenue on own spending on health. This means greater commitment of public finances to health, when analyzed in comparison with the other regions. It is worth noting that the economically well off region of Greater ABC, with available per capita revenue of R$ 1,727.67, commits a mere 25.9% spending on health per capita; R$ Another commitment even larger than that of this region is the per capita revenue available in Vale do Ribeira (R$ 1,346.90), corresponding to per capita spending of R$ , 27.7% of tax revenue, in the form of transfers. Areas 2 and 3: Health conditions and health surveillance Concerning health and living conditions and health monitoring, a large set of indicators was identified. Vital statistics on infant mortality indicate that, in 2011, the Baixada Santista health area has the highest coefficient, per thousand live births, compared to other regions, and is substantially higher than that of the state: (Table 2). The same result is shown in relation to maternal Saúde Soc. São Paulo, v.24, n.2, p , Table 1 - Socio-economic and budgetary health indicators from Area 1, the MR of Greater ABC and Baixada Santista, Vale do Ribeira and Bauru. São Paulo State 2011 Indicators/period Socio-economic indicators Budgetary indicators São Paulo State Greater ABC RM Baixada Santista Vale do Ribeira Bauru Region Population 41,587,182 2,566,690 1,678, , ,410 Demographic density hab./km2* , Urbanization rate (%)* Sewer network (%) * Rate of illiteracy aged 15 and over * Annual population growth * Femininity index Ageing rate Percentage of elderly Birth rate GDC per capita (R$) 32, , , , , Tax revenue and const. transfers per capita 1, , , , , Own spending on health per capita (R$) Own revenue applied in health. (%) EC Total health spending per capita (R$) SUS transfer revenue per capita (R$) Total SUS transfer spending (%) Source: IBGE, SES/SP and SIOPS. *Data from 2010 census. mortality, with a rate of per thousand live births, higher than that of other regions and the state itself (39.36). In fact, it can be seen that the data for the mortality group show the worst results in the Baixada Santista region (Table 2). The best situation for most indicators of this group is seen in the Vale do Ribeira region, except for mortality from prostate cancer, the Greater ABC region (12.99 per hundred thousand) and mortality from external causes in the Region of Bauru (50.72 per hundred thousand) (Table 2). Regarding the morbidity and other groups, the worst results were identified in the Bauru region in the prevalence of dialysis patients (54.90 per 100 thousand inhabitants) and the hospitalization rate for older people with hip fractures (27.48). The Baixada Santista Health Region got the worst results in relation to the incidence of congenital syphilis (3.06), the proportion of live births to teenage mothers (15.87), calculated using the number of births with information on the mother s age (considered births), and the conditions accompanying the Bolsa Família Program coverage (PBF) (45.73%). In the proportion of live births with low birth weight and stroke hospitalization rate per 10,000 inhabitants over 40 years old, insufficient results were shown in the regions of Greater ABC (9.43) and Vale do Ribeira (27.87) respectively (Table 2). Analyzing the best results, we note that the Vale do Ribeira Region covers most of the indicators. The following were recorded: congenital syphilis incidence rate (1.92), proportio
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