Digital Health Institute
Joaquim Cardoso MSc.
April 6, 2022
This is an excerpt of the report “Brazil’s Primary Health Care Financing — Case Study”, Chapter “Challenges for scaling up the FHS (Family Health Strategy)”, Section “Health System governance”.
The original text was not edited. Only an excerpt was made, reading it from a “Governance lens perspective”.
Massuda A, Malik AM, Lotta G, Siqueira M, Tasca R, Rocha R Brazil’s Primary Health Care Financing: Case Study. Lancet Global Health Commission on Financing Primary Health Care. Working Paper №1. 2022
The focus of the original report is to “… discuss how challenges in health system financing, governance, resource allocation and in management capacities at the municipal level have shaped the PHC (Primary Health Care) model across the country”
Therefore, this excerpt, focused on the topic of Governance, should be read in that context.
In the final part of this excerpt we also reproduce the “Conclusions” of the original report, covering all the dimensions mentioned before.
Key messages
The 1988 Constitution enhanced municipal responsibilities for providing public services …However, it established that the federal government should … support its implementation by lower levels of government.
- … the coalition of tripartite management groups (CONASEMS, CONASS, MoH), which created a political and social basis to support the implementation of SUS including the approval of PHC policies, was not strong enough
- As a result, municipalities had to undertake responsibility for managing the health system without support from state governments
Disparities between municipalities, the low level of participation of state governments and the lack of effective regional governance instruments, hindered the integration of PHC services into healthcare networks.
- From 2001 to 2013, four attempts were made to improve the Governance of the Brazilian Health System (summary by the editor of the blog)
- However, all these efforts were neither supported by new substantial financial incentives nor by a regional managerial structure … (see comments below)
- [I9] Funding alone is not enough to organize the network.
Health regions need a managerial structure able to coordinate,
and a legal and operational mechanism to ensure administrative, bureaucratic, and managerial competence.
- [I13] Regionalized planning is not enough if the consolidation of regionalization is not encouraged.
The financing unit should be the health region rather than the municipality, but the municipal manager is not keen to assume new regional commitments with the MoH without deriving additional benefits from it.
Conclusion
- Implementing a universal and comprehensive health system in a country with widespread inequality was a major achievement in Brazil.
- However, unresolved structural problems in Brazil, which remains one of the most unequal democracies in the world, and the fragilities of the health system have limited the reach of the FHS.
- Looking ahead, as a prolonged economic and political crisis unfolds in the country, dramatically exacerbated by the COVID-19 pandemic, replacing the successful PHC financing model by simply redirecting the existing resources according to new criteria, is foolhardy.
- Capitation can be a valuable enhancement of the financing mechanisms for PHC in Brazil if it is integrated with the successful PAB scheme in a blended model.
Health System governance (excerpt)
The 1988 Constitution enhanced municipal responsibilities for providing public services by giving municipalities financial, administrative, and political autonomy, based on the assumption that municipalization was the best way to strengthen democracy.
However, it established that the federal government should define national priorities, design policies and create mechanisms for supporting its implementation by lower levels of government.
The role of state governments, to coordinate national policies at the regional level and balance local differences, was poorly executed.
As a result, implementation of the SUS and expansion of PHC took place under widely unequal conditions and contradictions.
The 1988 Constitution enhanced municipal responsibilities for providing public services …However, it established that the federal government should … support its implementation by lower levels of government.
The role of state governments, to coordinate national policies at the regional level and balance local differences, was poorly executed.
Decentralization to the municipal level allowed the construction of a unified health system in a continental country, reducing inequalities by including smaller and poorer municipalities in the SUS.
However, given the significant regional heterogeneity and socioeconomic disparities in the country, considerable differences in the technical and administrative capacities of the municipalities created distinct differences in service delivery in PHC and integration with healthcare networks.
Decentralization to the municipal level allowed the construction of a unified health system in a continental country, reducing inequalities …
However, … created distinct differences in service delivery in PHC and integration with healthcare networks.
Furthermore, the coalition of tripartite management groups (CONASEMS, CONASS, MoH), which created a political and social basis to support the implementation of SUS including the approval of PHC policies, was not strong enough to create a better design for health system organisation and governance at the regional level.
Furthermore, the coalition of tripartite management groups (CONASEMS, CONASS, MoH), which created a political and social basis to support the implementation of SUS including the approval of PHC policies, was not strong enough
As a result, municipalities had to undertake responsibility for managing the health system without support from state governments, as mentioned by the interviewees:
As a result, municipalities had to undertake responsibility for managing the health system without support from state governments
[I8] States own certain health resources, scale, and infrastructure that are scarce at the municipal level;
they can contribute more to the solution of PHC services.
[I13] The states’ budgets for PHC did not increase enough,
especially when compared to the spending of municipalities.
In turn, the states do not adequately exercise the role of PHC coordination — to train and motivate FHS teams, and to agree and monitor health and quality indicators in municipalities within their jurisdiction.
[I13] We have not been able to advance and build a clearer obligation for states concerning PHC funding, despite the discourse that
a) PHC is a priority and b) PHC is the organizing principle of the health network, and c) the PHC funding is tripartite.
Disparities between municipalities, the low level of participation of state governments and the lack of effective regional governance instruments, hindered the integration of PHC services into healthcare networks.
Consequently, while the PHC financial arrangement was able to increase FHS coverage, it was not able to encourage FHS integration into health networks.
Disparities between municipalities, the low level of participation of state governments and the lack of effective regional governance instruments, hindered the integration of PHC services into healthcare networks.
In 2001 and 2002, the MoH first attempted to organise hierarchical networks and set healthcare operational rules (Normas Operacionais da Assistência à Saúde — NOAS) …
… by developing guidelines for an integrated planning process for distribution and financing of PHC, specialized and hospital services, and organizing them into health regions.
In 2006, new guidelines for health system organisation and financing were defined by the Health Pact (Pacto pela Saúde),…
… assembling several federal financial incentives into six financing blocks, including Primary Health Care.
In 2011, presidential Decree 7.508 introduced contracts among the three levels of government to organize networks of services in health regions, …
… reinforcing the role of PHC services as the main “front door” for accessing the SUS.
From 2011 to 2013, the MoH introduced a group of policies that set out guidelines and reoriented federal funds for integrating healthcare services in networks — for Maternal health, Emergencies, Mental Health, Disabilities, and Chronic diseases — by region.
The policy was designed to overcome fragmentation and inequalities in funding of the health system and proposed to strengthen PHC as the basis for health regions with defined populations and territories.
From 2001 to 2013, four attempts were made to improve the Governance of the Brazilian Health System (summary by the editor of the blog)
However, all these efforts were neither supported by new substantial financial incentives nor by a regional managerial structure …
However, all these efforts were neither supported by new substantial financial incentives nor by a regional managerial structure, limiting the ability to promote the integration of PHC services into health networks. Some interviewees explained these challenges:
[I2] Regionalization is aimed at encouraging networks, in order to bring the system together.
However, it lacks clearer political agreements and a better alignment of incentives between the provision and financing of services between ‘importing’ and ‘exporting’ municipalities — those receiving or sending patients to neighbouring municipalities within the health region.
[I5] The proposal of the health regionalization pact was innovative in terms of regional planning, but states were initially concerned about joining in and having increased expenses.
[I9] Funding alone is not enough to organize the network.
Health regions need a managerial structure able to coordinate,
and a legal and operational mechanism to ensure administrative, bureaucratic, and managerial competence.
[I9] Funding alone is not enough to organize the network.
Health regions need a managerial structure able to coordinate,
and a legal and operational mechanism to ensure administrative, bureaucratic, and managerial competence.
[I13] Regionalized planning is not enough if the consolidation of regionalization is not encouraged.
The financing unit should be the health region rather than the municipality, but the municipal manager is not keen to assume new regional commitments with the MoH without deriving additional benefits from it.
[I13] Regionalized planning is not enough if the consolidation of regionalization is not encouraged.
The financing unit should be the health region rather than the municipality, but the municipal manager is not keen to assume new regional commitments with the MoH without deriving additional benefits from it.
6. Conclusion (excerpt)
Implementing a universal and comprehensive health system in a country with widespread inequality was a major achievement in Brazil.
Influenced by the political impetus to restabilize democracy and increase social rights, and inspired by creative municipal experiences in different regions of the country which sought to overcome adversity, the Family Health Strategy was applied nationwide.
The FHS used financing arrangements that combine federal incentives, composed of fixed and variable components, with municipal resources.
The model showed an efficient and effective way to improve access and health outcomes, especially for the poor, serving as an example of innovation for Latin American and other low-income countries.
However, unresolved structural problems in Brazil, which remains one of the most unequal democracies in the world, and the fragilities of the health system have limited the reach of the FHS.
Financing arrangements were not robust enough to face challenges such as imbalances in the allocation of health professionals, the poor quality of some PHC provision, the need to introduce innovative health technologies and to integrate better with health networks.
Looking ahead, as a prolonged economic and political crisis unfolds in the country, dramatically exacerbated by the COVID-19 pandemic, replacing the successful PHC financing model by simply redirecting the existing resources according to new criteria, is foolhardy.
The PAB was an arrangement that, despite its issues, was fundamental for creating stability in PHC financing.
In moments of crisis, such as the current COVID-19 pandemic, the need for a consistent financing scheme for PHC is crucial.
Capitation can be a valuable enhancement of the financing mechanisms for PHC in Brazil if it is integrated with the successful PAB scheme in a blended model.
Health inequalities are already increasing rapidly, mainly affecting that part of the Brazilian population which benefited most from the Family Health Strategy over the past two decades. These setbacks should not be ignored but reversed, in order to continue to support the fabric of society.
Original publication @
