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This article presents a methodological proposal for analyzing the determinants of the offer of healthcare, starting with the dynamics of capital accrual, to be added to the health policy definition elements conventionally employed in the Collective Healthcare field. The analysis is based on the methods and ideas of Industrial Economics, already tested, where the healthcare sector is concerned, within the European context and by CEPAL researchers. To this, it proposes to add variables from the general context, which condition possibilities and impose limits upon the strategies of local agents, as well as analyses of a historical nature that allow one to identify rough patches. It has the purpose of providing support for the state and municipal managers of the Single Healthcare System (SUS), as the sole administrators of the healthcare sector in a given territory, which includes the set of possibilities of private sector regulation - from the planning of supply to its quality control.
Apresenta-se uma proposta metodolgica direcionada anlise dos determinantes da oferta de ateno sade, com base na dinmica da acumulao de capital a ser agregada aos elementos de definio das polticas de sade mais convencionalmente empregados na rea da Sade Coletiva. A anlise est baseada nos conceitos e mtodos da Economia Industrial, j testados para o setor sade em trabalhos desenvolvidos no mbito europeu e por pesquisadores da CEPAL, aos quais se propem agregar variveis do contexto geral, que condicionam possibilidades e impem limites s estratgias dos agentes locais, e anlises de corte histrico que permitam identificar rugosidades. Destina-se a apoiar os gestores do SUS, estaduais e municipais, na sua atribuio de comando nico do setor sade sobre um determinado territrio, o que inclui o conjunto das possibilidades de regulao do setor privado - do planejamento da oferta ao controle de qualidade.
El artculo presenta una propuesta metodolgica cuyo objetivo es analizar los determinantes de la oferta de atencin a la salud a partir de la dinmica de acumulacin del capital, a ser aadida a los elementos ms tradicionales de evaluacin de las polticas de salud utilizados en el campo de la Salud Publica. El anlisis esta asentado en los conceptos y mtodos de da Economa Industrial, probados para el sector salud en trabajos ya desarrollados en el mbito europeo y de la CEPAL, a los cuales se propone agregar variables del contexto socio-econmico-poltico general. Estas variables abren posibilidades e imponen lmites a las estrategias de los agentes locales. Estudios histricos que permitan identificar rugosidades, de acuerdo con el planteamiento de Milton Santos, tambin son aportes importantes. El trabajo se propone apoyar los gestores del Sistema nico de Salud de niveles estadual y municipal en su rol de comando nico de la salud de un territorio. Esto incluye el conjunto de las posibilidades de efectuar la regulacin del sector salud: desde la planificacin de la oferta hasta el control de la calidad de los proveedores.
The article presents a proposal of a methodology aimed to analyze the health care sector according to the dynamics of capital accumulation. That approach could be summed up to more traditional approaches founded in the Public Health field, based in a political perspective. The proposal departs from concepts and methods of Industrial Organization, already used for health care markets, in the European and Latin-American (CEPAL) contexts. We aggregated economic and historical variables to these approaches, which delimitate possibilities and impose constraints to the strategies of the local agents. The objective of the paper is to give methodological support to public managers at state and local level, whose role as the single commander in their territories is prescribed by the present health policy in Brazil. That includes all the fields related to private sector regulation in health: from planning the supply to quality control of providers.
Analysis of health services supply is a decisive component of health planning. With the implantation of the Unified National Health System, in Brazil, that stimulates an ample process of decentralization in the country, regional and local instances of government and Health Councils that include organized civil society members have been ever more engaged on the proposals and follow-up of Health Plans, in accordance with the guiding lines of the NOB-96 and the NOAS-01/02. One of the chief characteristics of the Brazilian health system is the interpenetration of public and private interests, both in the financing and the delivery of health services. However, it has been usual to analyze these instances separately. In general, the state and local health systems have restricted their control of the private sector to the proceedings financed through the public health funds to complement public health services supply, aiming at adequate coverage. This, in spite of the more inclusive responsibilities of the State that include the private health sector in its totality, as, for example, in the guarantee of the quality of services, the strategy of incorporation and dissemination of technologies and medicine and health materials consumption. The process of regulation of the so called supplemental health attention, that is, those proceedings provided through private health insurance has been assumed in Brazil by a specific federal regulation agency. This agency has acted mainly through direct action on the subjects of its regulation throughout the country, in contrast to all the legislation of the health sector that, after the 1988 Constitution, points to the integration between the federal, state and municipal levels and the reinforcement of municipalities as the main managing instance of the health services. This agency has assumed some actions that were widely discussed in the process of the Brazilian sanitary reform of the 1980s, as being more effective when developed at the local level, as is the case of quality control of health services delivery and the guarantee of universal access, through the development of loci of social control on the Health Councils.
In Brazil, little is known about the impacts of the growing private insurance as an alternative of financing for almost 25% of the total population (this can be as high as 50% in some metropolitan areas)on the Unified Health System. Some of the impacts have been known for a long time, such as the double militancy of health professionals deviating demand from and reducing working time at public institutions, or, providing a differentiated access to some high cost exams and procedures as hemodialysis, prothesis, among others. The frequent crossing-over between the public and private systems claims for politics and methodologies that consider the problem in an inclusive and integrated manner.
This article proposes to contribute to the development of methodologies that allow a systemic understanding of the structure and dynamics of the health services, in a perspective that contemplates public policies not only as motor forces of its development, but also as what we will understand as the dynamics of the capital. This dynamics will be studied through the general structural trends of accumulation of the capitalist society, as well as through the more specific intra-sectorial processes of competition.
It matters for the policy makers (the controllers of the health sector and the agents of the social control), to know the structure of the market and the nature of the competitive processes that occur among the producers of services and how it changes in time and the economic conditionings of such changes, as well as the more general social and political ones. That is, its dynamics. The decisions that are taken within the health sector, that conforms it and establishes the standards of practice and health consumption, that have impact on the health situation of the people, do not occur only in the public sphere, mediated by the State. It may not even occur mainly in this sphere. Although the dynamics of the markets of insurance and services should be taken in consideration by public managers, including at the local level, this is seldom done or not done at all, and, when attempted, is frequently based on empirical premises. Many areas that constitute the routine work of public health institutions lack the conceptual elements to establish their politics, in all the geographic and functional levels of the system as, for example, the sanitary monitoring, the delivery of healthcare and the development of human resources.
It is not enough to have the administrative description of the facilities with its respective institutional arrangements, and indicators of production, coverage and results. What is intended here is to develop an answering dimension of healthcare supply that can forge each configuration with its distinct results, with trends expected from the development of determinant variables and with the possibility of public regulation of these variables. Also, we aim to identify the market structures and dynamics that can be better adjusted, which implies in different public policies that favor one or another economic agent. And also, that evaluates where market elements should be valued and where it would be better if they were suppressed.
It has been noticed, since the 1990s, an increasing interest of international organizations, as the World Health Organization, in the development of public-private partnerships for the reach of health goals (RIDLEY, R.G. 2001). Many strategies have been presented by MILLS et alli (2002), and they conclude for the necessity of a better understanding of the behavior of the private providers in order to better influence them. Experiences in this direction have been promoted and evaluated for the control of transmissible diseases (NEWEL et alli, 2004) and, less frequently, of non-transmissible diseases (NISHTAR, 2004). This work aims to collaborate in the identification of areas of cooperation and areas of conflict in public-private relations, and, consequently, where the partnership strategies are possible and desirable and where they are only reached with a reasonable resignation of the public interest.
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