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ARTCILE
challenges in the Legal Amazon Region: an analysis
of the QualiSUS-Rede Project
governmental stakeholders and low coordination Likewise, in the metropolitan area of Belém,
with other segments of government or society, as at the time of the QualiSUS-Rede project, CIR
per Chart 1. had not yet been established. During the im-
In the Alto Solimões region, the steering plementation, the participation of the represen-
group was set up before the establishment of the tatives in the steering group (SG) was neither
Regional Interagency Commission (CIR). Initial- consistent nor uniform. Nonetheless, it was pos-
ly, this group counted on the participation of the sible to formalize partnerships with the state uni-
directorate of the Garrison Hospital (of the Min- versity for professional training and permanent
istry of Defense), an important back-up in the education, as well as to make diagnostic support
region, and with a representative of the Federal available via Telessaúde (equivalent of Telemedi-
University of Amazonas. However, this compo- cine). The participation of a philanthropic health
sition was later modified, keeping only managers facility in the SG was also mentioned, which is
and technicians of the health secretariats. Choos- responsible for back-up urgent and emergency
ing this region for the project was based on the services in the region.
existence of a strong indigenous component in Given the impossibility of involving manag-
the population composition. The incorporation ers of all municipalities, TOPAMA region’s rep-
of the indigenous health subsystem, through the resentatives were the municipalities of reference
participation of the three indigenous health dis- of their health regions. The SG was attended by
tricts (DSEI) of the region in the steering group, different technical areas and the management of
favored the coordination of demands and some state secretariats, COSEMS and local sponsors.
level of shared resources, although there were An indigenous health representative was later
divergences regarding regional priorities. The incorporated by integrating demands from this
region partnered with the Amazonas Regional area into the project.
Development Project for the Green Free Zone In the three cases analyzed, the political dis-
(PRODERAM), coordinated by the Amazon De- continuity resulting from the municipal elec-
velopment Company (CIAMA), in partnership tions with the turnover of the municipal man-
with the World Bank, which has health as one of agers implied additional steps of involvement,
its lines of action in the region. negotiation and new agreements of priorities. In
1214
Casanova AO et al.
Chart 1. Regional governance stakeholders of Alto Solimões, Belém’s metropolitan region and Topama.
Belém’s Topama
Stakeholders Alto Solimões Metropolitan
region TO PA MA
Chart 2. Strategies for strengthening regional governance in Alto Solimões, Belém’s metropolitan region and
Topama, 2014.
QualiSUS-
Alto Solimões Belém Topama
Rede Regions
Problem SUS management tools are Poor qualification The need to qualify and provide
Situation used infrequently, precariously of administrators, managers and technicians with the
and with little updating. The managers and necessary tools to develop and plan
necessary presence of the technicians in actions based on the conception
DSEIs and the Ministry of planning actions of networks and structures of the
Defense is a Tripartite Council aimed at designing regionalization process, such as
and not a Bipartite as required Health Care federative relations, public-private
by the current legislation Networks relations, internal management
capacities, financial sustainability, care
regulation and the establishment of
quality standards for the provision of
(public and private) services, as well
as management and performance
standards of health facilities, among
others.
Strategies To guide municipalities in the Training of health To elaborate the interstate directives
construction of planning tools; professionals and involving the CIR of the Topama
Organizing a workshop for the representatives region and to establish the Interstate
construction of COAP in the of civil society Regional Collegiate.
region in concepts of
To establish a quality networks, legal tools Train SMS and SES professionals in the
assessment system in and current projects elaboration of SUS planning tools
hospitals of the municipalities
headquarters of the
microregions and to build a
tool for the user satisfaction
evaluation survey
To purchase equipment and To conduct periodic meetings of
furniture for the structuring of the GC with previous discussions
CIR’s Executive Secretariat in the CIR and regional forums for
To support CIR and QSR’s the organization of the RAS and
GC meetings by providing implementation of the provisions of
airline tickets and lodging to its Decree 7.508 /11.
members.
Source: Brazil, Fiocruz, ENSP, DENSP/LASER16.
aged to move towards proposals more in line view to identifying common gaps and difficulties,
with regional needs. which resulted in the elaboration of a regional
In Alto Solimões, the project worked as a re- health plan. The group also sought to identify
gional articulation mechanism, providing meet- other possible financing sources at state or federal
ings and discussions among all municipal man- level, in order to prioritize, in the project, actions
agers and a greater leadership role in the coordi- lacking funds for the structuring of networks.
nation of the process by the state manager around In TOPAMA, each State chose specific lines of
regional objectives, despite hardships in recon- care to organize networks, according to their own
ciling different demands of the technical areas, interests. Funds were equally distributed and
such as the indigenous subsystem and municipal each state signed a deed of undertaking and drew
interests. Initially, municipalities’ demands were up a specific procurement plan. Different move-
considered, based on their respective health plans. ments were identified for implementation of
A health map the region was elaborated with a actions among states, depending on the impor-
1217
In TOPAMA, it was mentioned that the main As for the planning and management tools
results achieved were the scale-up of articula- for the organization of networks, there were
tion and integration among the states; greater different responses among regions, encompass-
knowledge of the region’s reality, qualification ing both those indicated in the Health Pact and
of managers and technicians and advances in the those designated in Ordinance Nº 4.279. In the
definition of flows, regulation and integration of three regions, the definition of network flows,
services, starting with the oncology care network. the management pact, municipal health plans,
The issue of regulation was recurrent in the regional plans, management reports and, in par-
agenda of the several meetings we had, so that ticular, the action plans and terms of adherence
this Chronic Disease Care Network could work, formulated under the thematic networks were
so much so that it brought in regulation, protocol referred to interchangeably. Regulatory manage-
discussions and service organization discussions ment systems and a monitoring system based on
(GC-TOPAMA-21022). SisPacto indicators were also mentioned.
Conceived as one of the main contributions
of the project in the three regions, health trans- Co-financing and sustainability
port never took off the ground. Proposals were One of the main strategies of continuity and
deemed unviable by concentrating on the acqui- sustainability in Alto Solimões was the establish-
sition of transport (land and/or river) and/or the ment of a public health consortium, created with
contracting of passenger services, without the the purpose of enabling regional health manage-
establishment of a structuring plan (route plan, ment, reducing costs and expanding assistance.
flow organization, regulation, definition of re- Association with PRODERAM contributed to its
sponsibilities and costing). The lack of regional formalization.
experiences and an executive project model with- In Belém, few respondents were able to men-
in the MS itself were aspects that contributed to tion strategies for continuity and sustainability
the failure to advance in a consistent proposal. of interventions. They mentioned the impor-
The project execution schedule was also insuffi- tance of state co-financing in PHC, medium and
cient, given its complex design and implementa- high complexity, as well as the investments made
tion. in the qualification of the state regulation center
With regard to indigenous health, a priority and integration with municipal systems. Efforts
in the Alto Solimões and TOPAMA regions, it made for the establishment of the CIR and the
was sought to promote the articulation of de- elaboration of its internal rules were also deemed
mands of this specific population in the projects. important for the strengthening of regional gov-
In placing the responsibility of managers with ernance.
regard to the health of the indigenous popula- In TOPAMA, some respondents highlighted
tion on the agenda, both regions considered that that there are conflicts in the definition of re-
the project provided progress in integration, al- sponsibility between entities. Some stakeholders
though it did not occur as desired: argue that this definition was not formalized,
[...] One of the great advances of the QualiS- considering that the COAP was not signed. Most
US-Rede Project ... besides integrating the discus- respondents were not aware about co-financing
sion with the Municipality and the State, in this strategies or proposals for the sustainability of
case, covering three States on indigenous health, the implemented actions. Those who identified
was to make municipal and state managers aware them described continuity of interstate colle-
of their responsibility to this population. This was giates, federal funding and co-financing of states
a great gain for us, people of indigenous health and municipalities. Strategies and recommenda-
(GC-TOPAMA-15103). tions for network sustainability and strengthen-
We have integrated the PHC Network of the ing of regional governance are summarized in
municipalities with the Indigenous Health Dis- Chart 3.
tricts. Today, we can speak a closer language, al- Reflections were made on managers’ real
though it is not ideal yet. And we were able to define commitment to the agreements made and on a
some flows from PHC to secondary care, addressing certain understanding that regional governance
PHC for the Urgent and Emergency Network, per- would be restricted to meetings that occur in re-
haps this is the main thing (GC-AS-5). gional collegiates, disregarding that their imple-
mentation relies on the effective operation and
articulation of all the agreed actions.
1219
Chart 3. continuation
Regional Coordination
Alto Solimões Belém Topama
Advances in regional planning: Advances in regional planning: Advances in regional planning:
Window of opportunity established Strengthening planning Strengthening interstate regional
for the region to support its for regional issues. Active planning and perspective. Scale-up of
regionalization process. Efforts participation of state regional articulation and integration between
for synergy between the various unit in the discussion venues states. Greater knowledge of the region
proposals that have started to be (GC and CIR). Emphasis on and alignment of strategies required.
region-oriented. Preparation of a discussion with local councils. Qualification of municipal managers.
regional plan not yet validated by Hardships in providing greater capillary
the CIB. Preparation of a regional definitions - multiple settings (CIR,
plan. CES, CMS) considering the 3 states.
Elaborating the “Guidelines, objectives
and targets” and proposed regulations for
interstate CIR. Awaiting CIBs’ approval
and CIT guidance.
objectives in view of the poor existing services of municipalist, political-partisan, economic and
network, mainly in the medium complexity. Dif- privatist interests, in an unfavorable context of
ficult access, transportation, communication and low formalization and institutionality14,15. Results
connectivity implied initial investments in the indicate that these aspects were also found in the
diagnostic and logistical support. regions of this study, during the implementa-
Albuquerque21 points out in a study carried tion of the Project. There was recognition in all
out in the Amazon Region that the regional- regions that QualiSUS and the implementation
ization process in the states was directed to the of networks contributed to the strengthening of
organization of networks and flows, which also regional governance with differentiation between
occurred in the regions studied here, in addition cases, depending on the capacity of management
to the expanded installed capacity. and production of consensus among the stake-
As found in other studies, the CIR was the holders over regional and political priorities.
main governance strategy15,22. It should be noted However, regionalization and its governance
that the three regions started the Projects before are processes under construction that need to be
CIRs were even established. The QualiSUS-Rede matured. The priority given to political, electoral,
Project contributed to boost the formalization of municipal and state aspects, to the detriment of
these articulation arenas. However, the need for the technical aspects, problems in combining the
a differentiated composition in Alto Solimões diversity of interests of many stakeholders, dif-
and in TOPAMA reflects the hardships faced by ferent institutional capacities, changes in man-
regional specificities before the need to adapt to agement and staffing resulting from electoral
current regulations. In the case of Alto Solimões, processes, difficulties in defining responsibilities
there was an interest to establish a tripartite par- among different entities and in establishing the
ticipation, including the Ministry of Defense, due transparency of decision-making processes and
to the Garrison Hospital. In TOPAMA, in the in- the diversity of planning and management tools
terstate region there was a limitation of manage- with overlaps and sometimes lack of articulation
rial participation in more than one formalized are factors that hamper regional planning and
health region. The lack of rules and tools that significantly limit progress and consolidation of
facilitate formalizing agreements in interstate re- regionalization.
gions is also noteworthy22. The rules of federative The low participation of other stakeholders
design are coupled with the regionalization pro- in the discussions and definitions of the regional
cess, disregarding that regions can have differen- agenda continues to indicate intersectoral artic-
tiated territorial divisions. How can we ensure ulation hardships in the regions14. As a result, it
the participation of an entity in more than one becomes harder to strengthen a health region-
regional management area: that of state health alization articulated with economic and social
region and of the interstate region? These are is- development projects, fundamental for over-
sues that need to be considered. coming the limits imposed by structural regional
In the period and regions analyzed, the tech- inequalities that characterize the Legal Amazon
nical realm of network formation seemed to Region19,20. In territories characterized by lower
gain prominence and priority in relation to the technical and normative density, rarefied terri-
political realm, which was compromised for torial fluidity and forgotten by the interests of
some reasons: firstly, because the collaboration modern hegemonic economy, it is important to
agreement between federative entities through strengthen partnerships with other institutions,
the COAP did not materialize; second, because to expand the scale of action and interaction,
in two regions (Alto Solimões and TOPAMA), even with other regions, in order to enable pro-
while regional plans were elaborated, they were cesses, expand governance capacity in the territo-
not signed in the respective CIBs. Moreover, in ry and reduce its dependency ratio20.
terms of financing, there are no definitions of The efforts made by the different stakehold-
possible financial arrangements, especially in the ers to reflect the regional reality and define their
(international and/or interstate) border area14,21. priorities should not only be maintained, but en-
Another important aspect is that the strong fed- hanced, with a view to increasing the governance
eral induction for the establishment of thematic capacity, in order to overcome a procedural, rit-
networks may have been a constraint for the or- ualistic perspective and to achieve a constitutive
der of regional priorities. governance, whose processes include formula-
Recent studies indicate that regional gover- tion, formalization of agreements and regional
nance has been characterized by a predominance planning based on its priorities.
1223
Collaborations
Acknowledgements
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