Cooperação e Coordenação na Implementação de Políticas Públicas: O Caso da Saúde

Abstract

A implementação da maioria das políticas sociais demanda a integração de ações dos diversos níveis de governo, o que remete ao problema teórico clássico sobre a possibilidade de ação coletiva ou de cooperação entre entes autônomos. Em contextos federativos, a cooperação remete a questões analíticas como a coordenação federativa, a definição de arenas federativas para construção de acordos entre os entes federados e as condições nas quais seja possível a cooperação.No processo dinâmico de implementação da política de saúde no Brasil, definida a partir da Constituição de 1988, tem sido desenvolvido um arcabouço institucional complexo para lidar com essas questões, após um momento inicial de descentralização com forte ênfase municipalista 1 . Destaca-se, nesse processo, a tentativa de construção de sistemas regionalizados que ultrapassam o espaço municipal e envolvem articulação e cooperação entre as instâncias governamentais com vistas a garantir o acesso dos cidadãos aos diversos serviços de saúde, http://dx

O desempenho dos municípios no Pacto pela Saúde no âmbito das relações federativas do Sistema Único de Saúde

“…Since its implementation, there has been a constant evolution of the regulatory framework of federative relations. In order to face one of the central dilemmas of federalism (to concile autonomy and interdependence of federated entities), it has been tried to define mechanisms and instruments of regulation that promote cooperation and coordination, in order to guarantee uniformity of policy and universality and integrality of attention (Menicucci, 2014a, 2014b, Menicucci et al, 2008, besides creating incentives to transfer responsibilities and combat competitive and predatory relations between the Union, states and cities.…”

“…In this arrangement, the Union is responsible for standardization and general coordination; the federal government has control of the decisionmaking process, defines the format of cooperation and the allocation of transferred resources, while cities are executors and managers of this policy (Arretche, 2012;Menicucci, 2014b;Menicucci et al, 2008). The main mechanism of regulation, which defines the nature of intergovernmental relations, is the distribution of resources for system costing.…”

“…The very dynamics of institutional rules aimed at overcoming difficulties in health care in territories that go beyond the political and administrative limits of the federated entities is an expression of the difficulties in the construction of regional networks. Studies have pointed out that the institutional arrangement has not guaranteed regionalization success (Menicucci, 2014a, 2014b, Menicucci et al, 2008. Even if the Union regulates and defines incentives for the alignment of federated entities with national guidelines, regionalization is affected by the context and behavior of regional and local actors.…”

“…In this sense, indicators such as tetravalent vaccination coverage and coverage of the Family Health Strategy (ESF), although presenting significant percentages of compliance with the goals, varying between 80% and 70% of the cities, respectively, have lower results than other indicators, such as EC29 and CNES. Possibly, the worst relative result is due, in the first case, to the dependence of the population's willingness to be vaccinated and, secondly, to the need to be able to fix health professionals, something more difficult in distant areas (Menicucci, 2014b).…”

Pacto pela saúde: aproximações e colisões na arena federativa

“…Although considering that this process was developed in a privileged manner in a joint federal arena of the Tri-partite Management Commission (CIT), Brazilian literature on federalism has suggested a leading role of the Union in forming and coordinating social policies, a point that we take here as a general hypothesis. Unlike previous studies that emphasized the implementation aspects 2 or results 3 , the present study aims to elucidate tensions and convergences between government levels in the Health Pact institutional construction process. Health policy in Brazil offers a fertile field for reflecting on the conditions and possible solutions of federal dilemmas, which is why we started this work by characterizing the distribution of vertical political authority between the three levels of government in the institutional configuration that emerged from the 1988 Federal Constitution.…”