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DOI: 10.1590/1413-812320172211.

20042017 3527

Continuous Cash Benefit (BCP) for disabled individuals:

ARTICLE
access barriers and intersectoral gaps

This article is also available in audio

Jeni Vaitsman 1
Lenaura de Vasconcelos Costa Lobato 2

Abstract The 1988 Constitution approved the


Continuous Cash Benefit (BCP) directed to el-
ders and disabled persons with a household per
capita income of 25% of the minimum wage,
and around 4 million people received this benefit
in 2015. The design of BPC for disabled persons
involves organizations of social security, social
welfare and health. This paper discusses how
some intersectoral coordination mechanisms gaps
between these areas produce access barriers to
potential beneficiaries. Results stem from a quali-
tative study performed with physicians, adminis-
trative staff and social workers from the Nation-
al Institute of Social Security (INSS) and of the
Social Welfare Reference Center (CRAS) in three
municipalities of different Brazilian regions. In-
tersectoral coordination and cooperation are more
structured at the Federal level. At the local level,
they rely on informal and horizontal initiatives,
which produce immediate but discontinuous solu-
tions. The role of the CRAS remains contingent
on the implementation. The need to establish in-
stitutionalized mechanisms for coordination and
1
Escola Nacional de cooperation between social welfare, health and so-
Saúde Pública, Fiocruz. R. cial insurance to improve the implementation and
Leopoldo Bulhões 1480,
reduce barriers to access to the BCP is apparent.
Manguinhos. 21041-210
Rio de Janeiro RJ Brasil. Key words Continuous Cash Benefit, Implemen-
vaitsman@ensp.fiocruz.br tation, Access barriers, intersectoriality, coopera-
2
Escola de Serviço Social,
tion, Coordination
Universidade Federal
Fluminense. Niterói RJ
Brasil.
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Vaitsman J, Lobato LVC

Introduction biomedical model of disability, involving social


movements, civil society organizations and in-
The Continuous Cash Benefit (BPC) is a welfare ternational organizations, a new disability assess-
right guaranteed by the 1988 Federal Constitu- ment model for BPC eligibility was established
tion to elderly persons aged 65 years and over in 20071 and implemented in 2009. Based on the
and to persons with disabilities whose family in- World Health Organization’s (WHO) Interna-
come is up to 1/4 of the minimum wage. With tional Classification of Functioning, Disability
amount equivalent to one minimum wage, it and Health (ICF), this new model has considered
benefited about 4 million people in 2015. Its im- deficiencies as problems in bodily functions or
plementation involves organizations from three structures, but within a social and personal con-
social sectors: social security, social welfare and text. Functionality and incapacity began to be
healthcare. In the case of people with physical or seen because of the interaction between health
mental disability, several barriers hinder access to states, environmental and socio-familiar contexts
benefit. Some of them are the result of the poor and participation in society. Persons with a dis-
coordination and cooperation mechanisms be- ability are eligible for the benefit if they have (in
tween health services, social welfare and social addition to a per capita household income of ¼
security. the minimum wage) “long-term physical, men-
The Ministry of Social and Agrarian Devel- tal, intellectual or sensory impairments which, in
opment (MDSA) is responsible for managing, interaction with various barriers, may obstruct
coordinating, regulating, financing, monitoring their full and effective participation in society on
and evaluating the Benefit, while the INSS is re- an equal basis with other persons”2. As a criterion
sponsible for its operationalization, including of long-term impediment, the law considers the
recognition of the right and concession, based on minimum period of two years.
medical and social assessments. Thus, the evaluation of the applicant for
In this paper, we discuss how some access purposes of granting the benefit, in addition to
barriers faced by people with disabilities in the medical examination, incorporated the social as-
benefit application process are related to gaps in sessment carried out by social workers, also from
the coordination and cooperation mechanisms the National Social Security Institute (INSS). It
between social security, social welfare and health is incumbent upon social workers to assess the
care. As other social policies, the intersectoral component environmental factors – physical and
nature of BPC stems from the adoption of ad- social environment and attitudes – that are bar-
vanced normative principles in its design and riers to the participation of persons with disabil-
formulation, but which were not followed in ities in society and some realms of the activities
management by coordination mechanisms that and participation component. The bodily func-
enable intersectoral cooperation in the imple- tions component, some realms of the activities
mentation. and participation component, specific aspects
The paper is divided into five sections, in of unfavorable prognosis, impairment of body
addition to this Introduction. In the first, we de- structure and long-term impairments are as-
scribe the characteristics of BPC for people with sessed by medical expertise.
disabilities; then we show the methodology of the Despite advances in the conception and oper-
research that originated this paper; in the third, ationalization of the evaluation, the granting of
we discuss the analytical categories related to the the benefit still relies quite a lot on the subjective
theme; in the fourth, we show some results and, character implicit in any judgment. It is difficult
finally, we submit the final considerations. to define uniform parameters3 or clear criteria so
that each individual is treated in the same way
BPC for persons with disabilities in the application process4. This extends to the
characterization of the disability degree of the
Since 1988, definitions of disability for disabled person. The expert evaluation should
granting the BPC have undergone several posi- consider both the severity and its persistence over
tive changes. Until 2007, the concept of disabil- time, which is fundamental for the granting of
ity inscribed in the law was strictly biomedical. benefit and that is not necessarily a concern of
Eligibility criteria were based on the concept of the physician who attended that person.
disability as an incapacity for independent living The evaluation also depends on the values,
and work resulting from bodily anomalies / inju- perceptions and even professional bias of those
ries. Resulting from a strong questioning of the involved in the various stages of the granting
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process. Diverse values, especially those relat- Analysis categories
ed to different professional cultures, can hinder
communication or involve divergent conceptions In order to discuss the extent to which access
about disability. Health professionals involved in barriers to BPC may be related to cooperation
the diagnosis of disability, independent living and coordination gaps, we briefly define these
and participation have different understandings, categories as they guided data analysis.
especially when it comes to people with some
physical or mental disability5,6. There are also Access
differences between medical professionals and
social workers. While physicians recognize the As an analytical category, access has already
importance of social assessment in the granting been widely studied and applied in the areas of
process, they express greater resistance to this health and education, but little in social security
partnership, as well as with regard to BPC objec- and welfare. In social security, access is regulated
tives5,7. by participation in the contributory structure.
Thus, access problems are more investigated re-
garding entry in the service, that is, difficulties
Research methodology and facilities that individuals face while request-
ing a given benefit. In welfare, due to the charac-
Data were collected in the second half of 2015 teristics of its target population, the investigation
from institutions and stakeholders involved in of access implies understanding not only aspects
the formulation and granting process: INSS and related to the moment of application, but also
MDS national managers, professionals – admin- those related to restrictions that precede and
istrative technicians; INSS medical experts and involve this request, such as information about
social workers – and potential beneficiaries, that the benefit, conditions to request and access the
is, BPC applicants. Although not necessarily par- implementing agencies, as well as the values and
ticipating in the granting process, which is oper- attitudes of the professionals responsible for the
ationalized by the INSS at the local level, social various stages of the evaluation. In the case of
workers of the Social Welfare Reference Center people with disabilities, it is important to under-
(CRAS) – the municipal unit that is the gateway stand how the relationships between the three
to the population service – may also have an im- sectors involved can facilitate or hinder access.
portant role in the referral of potential beneficia- Access to services involves cultural, geograph-
ries to the INSS. In order to verify intersectoral ic, economic, organizational and individual char-
coordination/cooperation at the local level, we acteristics. In our study, we took access as acces-
interviewed a social worker in each selected mu- sibility – that is, the components that facilitate or
nicipality. hinder access to the care service8-10. Accessibility
Three medium-sized municipalities (South- is related to the characteristics of the services that
east, Northeast and North) were intentionally allow their achievement and use, such as orga-
selected. Data were collected in agencies with a nization, geographic availability, ability to pay
significant number of professionals working in and acceptability8. In addition, access influencing
the granting process and in the high frequency factors are age, gender and values; conditions for
of beneficiaries and granting profiles, indicated arriving at and entering services; needs perceived
by the research contractor. The semi-structured by the patient or diagnosed11.
interviews sought to understand, according to These factors and realms, originally analyzed
the specificity of each segment, perceptions and for access to health services, can be applied to
positions regarding the access barriers related to other social services where there is an explicit
the study components. INSS professionals and need of the individual, as is the case of persons
applicants were interviewed at INSS agencies on with disabilities who access the BPC. In the re-
the days scheduled for the social and/or medical search, they were classified into three main com-
evaluation of the elderly and people with dis- ponents of access: the individual component, the
abilities. CRAS social workers were interviewed socio-familiar member and the organizational
at CRAS headquarters. National managers were component. In this paper, we specifically discuss
interviewed via Skype. We interviewed 30 appli- the barriers to access to BPC produced by the
cants, 15 professionals and 5 national managers. organizational component. We introduced the
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Vaitsman J, Lobato LVC

discussion related to intersectoral coordination to bodies from different social sectors. Hopkins
and cooperation gaps among organizations from et al.21 argue that, while diffuse, horizontal man-
different sectors involved in the implementation. agement can be a crucial means of managing
crosscutting issues related to certain policies or
Intersectoral cooperation and coordination the provision of some services. They may include
different types of linkages between stakehold-
The establishment of actions to achieve a ers and organizations involved: informal links
public policy objective is addressed by political facilitating mutual exchanges; coordination to
science as a collective action issue12-14. This im- reduce or eliminate overlap and duplication and
plies that the provision of a public good does not collaboration through resources, work or de-
occur voluntarily, but depends on cooperation cision-making processes are integrated into all
and coordination mechanisms, without which it organizations involved. Inadequate management
is unlikely to achieve sustainable results15,16. mechanisms produce significant barriers, while
In the case of policies or programs with in- more appropriate initiatives produce synergies
terfaces in different sectors, coordination and and lessen implementation problems, favoring
cooperation are even more crucial for achieving both implementing agencies and applicants. The
results17. Peters17 defines coordination as the need following results show barriers to access to BPC
to ensure that the various organizations involved related to intersectoral cooperation / coordina-
in providing some public service together do not tion gaps.
produce redundancies or gaps. Coordination lev-
els can be minimal or maximal. At the minimum
levels, organizations simply know the activities Results
of everyone involved and try not to duplicate or
interfere. At the maximum levels, there are strict- The intersectoral coordination and cooperation
er controls over the activities of organizations gaps will be discussed focusing on the relation-
and means to fill in service gaps17. Coordination ships between a) the INSS and welfare and b) the
mechanisms allow the adjustment of intersec- INSS and health.
toral policies and programs to increase their hor- a) Relationships between the INSS and wel-
izontal interconnections, with the possible shar- fare
ing of financial sources18,19. Relationships between the social security and
Cooperation is the joint action of a group of the welfare sector can take place within the same
individuals to achieve a common goal14. It is an federative level, for example between the MDS
interaction between sectors to achieve greater and the INSS, in the commissions and meetings
efficiency in their actions, involving the optimi- to address national benefit management; between
zation of resources while establishing formalities different federal levels, between INSS national
in labor relationships. Information sharing is the managers and municipal welfare administrators
first step for cooperation18,19. and managers; within the same municipality, be-
Although within a legal – normative – frame- tween INSS local agencies and CRAS.
work, activities related to the implementation of More structured intersectoral coordination
a policy can be organized in different ways. The and cooperation occur at the federal level, be-
mechanisms and processes can form different ar- tween INSS and MDS. Several joint initiatives
rangements depending on the local context15,20. have been taken in different areas related to the
The way stakeholders engage and create solutions implementation of the BPC, such as in regula-
from the rules produces the local forms of imple- tion, budget, elaboration of the new evaluation
mentation. model, in the training of INSS staff and in re-
While dependent on top-down relationships lationships with the CRAS. As a formal coordi-
that follow sectoral hierarchies, the implemen- nation body, a BPC Steering Committee was set
tation of intersectoral policies at the local level up with the participation of MDS and INSS to
may, to a greater or lesser extent, approach hor- discuss management problems, decision-making
izontal management forms, whose coordina- and referral of decisions to technical groups.
tion may be more or less loose, and cooperation The creation of the Monitoring Group for
transcends the boundaries between bodies and Disability and Incapacity Level Assessment
organizations. Particularly at the local level, hor- (GMADI) in 2010, made up of MDS and INSS
izontal relationships are responses to implemen- technicians involved in the definition, imple-
tation processes in which the citizen has to relate mentation and monitoring of the BPC grant as-
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sessment model, sought to coordinate this area in larger municipalities, also due to problems of
for the implementation of the BPC. The changes staff turnover and greater difficulty in contacting
in the conception of the evaluation were made the socio-welfare network.
in a working group composed by professionals The need to establish cooperation – generally
from the MDS and INSS. referred to as “partnerships” or “collaboration”
MDS normative acts are in place to guide in- – is consensual between national managers and
teraction between the INSS and the municipal among the various categories of professionals
management in relation to the concession pro- interviewed in the municipalities. Problems that
cess, but more structured forms of cooperation could be alleviated if INSS and CRAS local agen-
in the municipalities end up depending on the cies cooperated in a more structured way were
initiatives of the INSS local agencies’ manage- pointed out by the professionals involved in the
ment. Cooperation is usually contingent and not implementation of the BPC.
formalized, although attempts have been made to
establish covenants by agreement, a process that Entry information
has not gone forward.
Despite being agreed in the three spheres as The gateway to the request is scheduling for
part of the decentralized design of social pol- qualification at the social security agency by di-
icies, cooperation between the INSS and the aling number 135, a call-center service that pro-
socio-welfare network relies very much on the vides the first official information on the benefit.
political relationships of the federal government Ignoring the rules may be the first barrier. On the
with the municipal government and municipal day scheduled for the request, the applicant must
or even state management. There is no formal in- provide the INSS agency with the documentation
stance or legal instrument defining the tasks with of all members of his/her family group to prove
the objective of establishing cooperation mecha- income and family composition. However, the
nisms. The interactions and cooperation are in- family composition adopted by the benefit is not
formal and the responsibility for this interface is necessarily the same as that of the applicant. Of-
incumbent upon INSS’ social service. tentimes, the information given by number 135
Some places have partnered, even without hav- is not even understood to allow the applicant to
ing a formal institutional direction ... [...] So the ask questions.
INSS [...] the agencies talk to the social workers Applicants do not need to go through a CRAS
of the CRAS and the municipality. Social work- before the first visit to the INSS. However, if they
ers have a fundamental role in this process and do so, they can receive the proper information.
they seek this.... Last year, the MDS made several However, not always do CRAS social workers
regional meetings seeking both the INSS and mu- themselves know all the rules. Since CRAS has no
nicipal and state servants, etc. Thus, the need for formal role or authority in the application and
these partnerships was unison [...] However, some benefit decision process and social workers are
municipalities do not want to do that, they do not often overwhelmed with many other demands;
adhere. ‘No, this benefit is from the federal govern- they clarify, refer, and even provide assistance
ment, and so forth’... and ends with ...‘But most during the application, but this is not a regular
certainly want to; we at INSS want to, as it is im- initiative. The application process only begins, in
portant for us, because we improve our work, our fact, at the INSS agency.
flow (professional from national management). Several respondents suggest that CRAS could
Each of the 5,570 Brazilian municipalities have some registration mechanism before appli-
is free to adhere to joint management tools and cants arrive at the INSS agency. This is because if
mechanisms among the different federative lev- applicants do not carry the complete documen-
els. The party realm, especially when there is no tation when they file the application, they have
monetary incentive to adhere to federal policies, 30 days to return with requirements met, or the
can be an important barrier to interfederative co- process is rejected. Considering that applicants
operation. In addition, not all municipalities have are people with disabilities, in addition to social
INSS facilities, and applicants have to go to other and economic vulnerability and that most live far
municipalities to apply for the benefit, involving from the centers where the agencies are located,
a greater number of stakeholders in intersectoral the financial and emotional cost of travel is high.
relationships. In small municipalities, it is easier Both from the point of view of the INSS and
for INSS and CRAS social workers to cooperate the applicant, time and resources are wasted be-
to solve certain issues. This is more complicated cause the organizations involved cannot establish
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Vaitsman J, Lobato LVC

strong inter-organizational cooperation mecha- The institutional and personal performance


nisms. Other coordination mechanisms would of INSS servants is evaluated and measured
be necessary by higher instances besides already half-yearly from an annual action plan, with the
existing ones to make this happen. average service time being monitored by local
In the face of lack of information, vulnera- management. INSS-CRAS cooperation is local
bility, fear of facing red tape, resorting to an in- and informal initiative, producing horizontal
termediary becomes a solution at hand for appli- management forms. However, individual efforts
cants. INSS servants have little ability to interfere and informal ties allow for mutual exchanges
with intermediaries, because they cannot prevent prevail over institutionalized actions.
an applicant from being accompanied by another As the coordination between the local agen-
person, who is not placed as an intermediary, but cies of the INSS and the CRAS is poor or non-
as a “friend”, “neighbor” or “some acquaintance”. existent, nor is there a regular follow-up of the
The administrative staff complain a lot about rejected applicants by CRAS on the result of the
intermediaries, to whom applicants must pay if application. The welfare department is not aware
the benefit is granted. They also point out CRAS of cases referred and rejected, nor of the reason
potential to guide applicants as a way to alleviate for the denial. Knowledge about the outcome of
this issue. The widely accepted view among INSS the processes could prevent further referrals to
professionals is that the role of intermediaries INSS agencies from ineligible persons, as well as
would be greatly diminished if there were an ar- favoring support for incorrect dismissals.
ticulated network between INSS and CRAS. Oftentimes, the benefit is denied due to a
small excess income or, in the case of the disabled
Social evaluation person, if there is already another disabled per-
son benefiting from the BPC in the same family.
Once the application has been approved, While not eligible, these are vulnerable and have
social evaluation and medical examinations are difficult access to income. At the time of the sur-
scheduled. The social evaluation consists of an vey, a national INSS manager informed that they
interview with the social worker of the INSS, who were working together with the MDS in order to
has full autonomy to score the requirements of refer the rejected applicants to another policy in-
the social form, which, together with the medical stead of just leaving them there without any fur-
examination form, make up a sum of points that ther assistance.
establishes the approval of the application. The In this process, the relationships built de-
social evaluation process done at the INSS agency pend on the local context and the involvement
is highly criticized. The fact that the CRAS social of professionals in cooperation initiatives. In one
workers do not participate in the evaluation pro- of the agencies, after the introduction of social
cess, nor that their opinion is taken into account assessment, one respondent said there was an in-
in the process was seen by a respondent as a seri- ternal agreement to search for the social support
ous flaw in the system. network in the municipalities and areas covered
There are no formalized arrangements or any by the INSS agencies. This initiative allowed the
social information system about the applicant establishment of linkages with research institu-
shared between INSS and CRAS. There is a form, tions, the establishment of working groups on
namely, Social Information System (SIS), which, specific regional problems, the dissemination of
when in doubt, the INSS social worker completes tools and greater discussion within INSS agencies
and forwards through the applicant to the CRAS and integration with commissions and councils.
social worker to complete with some informa- b) INSS-SUS relationships
tion. However, the applicant himself must take Coordination and cooperation between INSS
the form and bring it back completed, which and SUS bring issues of another nature. There
makes the process quite random and slow. is a greater interaction between the INSS and
Contacts between CRAS and INSS are indi- mental health professionals, with more frequent
vidual initiatives and are limited by the deadlines meetings between social workers from the INSS
and goals established by the very INSS, since no and SUS from the area of mental health to ex-
servants are available for a permanent coordina- plain changes, exchange experiences and seek
tion with the CRAS. INSS organizational plan- solutions.
ning does not cover relationships with the CRAS Regarding physical disabilities or chronic dis-
and individualized actions can delay agency ser- eases, applicants have to submit medical reports
vice deadlines and threaten performance goals. for expert evaluation and there is no mechanism
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Ciência & Saúde Coletiva, 22(11):3527-3536, 2017


for coordination or cooperation with the SUS, at be associated with some chronic illness, such as
least at the locations of this study. heart disease, diabetes and that has repercussions
The medical examination carried out at the on the function and living and working condi-
INSS consists of an examination that verifies the tions. The role of the health network is therefore
medical report submitted by the applicant and crucial for the provision of information:
assesses whether the health condition attested by Because here we do not do health care, we do
the SUS is an impediment to independent living expert medical care ... So it is the recognition of the
and work for at least two years. In addition to right based on information that is technically and
not knowing that the patient needs the report to documental-wise proven. (Medical expert)
apply for the BPC, SUS physicians do not even The medical evaluation depends not only on
know what BPC is and therefore do not put into the set of documents or reports of the SUS, but
the report information that would be relevant to also on person’s proof that he/she sought assis-
the social security medical examiner. The medi- tance and that he/she is under medical treatment
cal documentation that the INSS expert receives for the condition that would generate the bene-
from SUS is often incomplete. The expert has fit. That is, he/she cannot claim a condition that
to assess the applicant’s clinical condition at the he/she has never tried to solve somehow, which
time of the examination and to check long-term implies in proving with appropriate reports and
compromised functions. This procedure requires exams of the SUS.
access to certain exams and some detailed in- The lack of examinations and the need to
formation, which the applicant does not always return to the SUS to obtain a new report or an
provide in his documents. The expert may is- examination would be an avoidable cost if the
sue a Request for Information to the Assistant physicians of SUS network already knew what
Physician (SIMA), an application that he prints documents the patient needs in order to file the
requesting the physician or health professional, application. With more knowledge about BPC,
psychologist, speech therapist, etc. to provide the SUS physicians could support access when they
missing information. The applicant himself must identify BPC eligible patients. Thus, they would
submit the SIMA to the attending physician, or need to know, have contact with the benefit and
someone else attending him/her to fill in data; the medical evaluation; or else, this could be
he/she may also ask for a copy of the medical through the intermediary of a health social work-
record at the health center or the hospital where er. The lack of information that is a barrier is not
he/she received treatment, which he/she cannot only on the part of the applicant, but also on the
always provide on time. part of the health professional.
So there is this difficulty with the applicant, Several applicants interviewed learned about
who sometimes lives in (another municipality) the existence of BPC at the health facility. In fact,
and until he/she goes there and manages it, he/she some health professionals know the benefit a lit-
depends on third parties to bring it back .... Then, tle and indicate to the patients, but as an individ-
they often know of this difficulty, and the applicant ual initiative. Social workers already include BPC
himself says: ‘It will take me three months to get in their professional practice, but they do not al-
this consultation’... Then, we evaluate based on ways know the benefit well and not all patients
that document and he/she will lose out on this... are attended by the social service department of
In the part of the bodily function, we have to fol- facilities.
low the medical documentation, so this is a barrier. As for the synergistic initiatives, a pilot of the
(Medical expert) INSS communication program with the health
There is no institutional communication system was developed in one of the agencies,
mechanism, systems do not intersect and com- with the construction of a form and the referral
municate. The medical evaluation or even the through the social worker to try to solve health
social evaluation are pending and the applicant care issues that prevented the applicant’s recov-
must return within 30 days, otherwise the benefit ery and kept him/her in the BPC. An inter-orga-
is denied. nizational cooperation between social workers
As the impact on independent living and and medical experts, as well as an inter-sectoral
work over the next two years should be assessed, cooperation between INSS and SUS was estab-
rehabilitation generally depends on the health lished, which eventually died out, according to
care network. One expert says that the main dif- the respondent, due to lack of adequate support.
ficulties are related to functionalities, which do It was a local, horizontal initiative that did not
not need to be related to a disability, but may also achieve sustainability.
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Vaitsman J, Lobato LVC

Final considerations social workers at the social security allowed a


greater approximation with the needs of the
The need to establish institutionalized coordina- beneficiaries, which stimulated the network of
tion and cooperation mechanisms with the social protection through referrals to other services and
welfare and health care sectors that can improve rights. However, they are also criticized by the
implementation processes and lower barriers to professionals themselves, since social assessments
access PCBs was clear. Federal administration are made at INSS agencies.
managed to establish intersectoral coordination Some processes related to BPC medical ex-
and cooperation tools and seeks to extend sim- amination that extrapolate the governance of
ilar mechanisms to local levels, where the policy the INSS local agencies and that depend on the
is implemented. However, these are slower pro- communication with the SUS network. Such
cesses because they rely on inter- and intra-fed- mechanisms, however, even when built by local
erative agreements involving a greater number of initiatives, to ensure their sustainability, rely on
instances and stakeholders. coordination mechanisms and incentives at the
The BPC is a welfare benefit, but as it is im- central levels.
plemented by the INSS, the role of the CRAS re- At the local level, several identified prob-
mains contingent. Since INSS is the gateway, the lems are sometimes solved by horizontal initia-
application process can be entirely isolated from tives, but would probably be more effectively
the care network. This refers to the design of the addressed by institutionalized arrangements
BPC. A welfare benefit granted by social security between the INSS, CRAS and the SUS, which in
is a contradiction that expresses a viable design turn depends on vertical relationships with cen-
to be implemented at first, but that with the con- tral decision-making levels.
struction of SUAS seems dysfunctional. The gaps observed and the solutions to the
Institutionalized coordination and cooper- problems involving the different institutions de-
ation mechanisms between local INSS agencies pend on informal linkages and relationships,
and the CRAS could improve the implementation which is a characteristic of horizontal and diffuse
process in a number of ways. The first would be forms of management. The problem of the vari-
to avoid scheduling ineligible persons, improving ous positive and synergistic intersectoral actions
flows and shortening applicants’ waiting time at from the local level is that they are not usually sus-
agencies. The second would be to improve public tainable. Local initiatives are more agile and un-
information, a crucial problem for the PCB. bureaucratized and depend on individual actions,
On the other hand, one must also acknowl- but are discontinuous and random. This is evident
edge that the BPC is a rather complex benefit in the initiatives taken by some local agencies that
with rules that are difficult to understand and were later discontinued. There are in fact contra-
over which applicants have no control. The vul- dictions between the individual unbureaucratized
nerability of applicants increases the barriers initiatives at the far end and the hierarchical struc-
produced by the lack of information, because ture of the INSS. Horizontal dynamics have not
they are unsure about the roles of each institu- replaced the vertical rationale of federal policies
tion and often not even what benefit they are and programs. To fulfill all the functions claimed
requesting. The role of CRAS could also reduce for the improvement of the BPC implementation,
the role of intermediaries, which have become a the CRAS must be better structured and recog-
solution from the viewpoint of the vulnerable, nized as participants in the decision-making pro-
uninformed applicant, who feels supported to cess on the granting of the benefit.
deal with red tape with which he is unfamiliar. This article did not incorporate the amend-
The introduction of social assessment in the ments made by the federal government from July
granting process in 2009 and the interview with 2016 to access to the BCP.
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Ciência & Saúde Coletiva, 22(11):3527-3536, 2017


Collaborations

J Vaitsman and LVC Lobato contributed equally


to the paper.
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Vaitsman J, Lobato LVC

References

1. Brasil. Decreto 6214 de 26 de setembro de 2007. Regu- 10. Frenk J. The concept and measurement of accessibility.
lamenta o benefício de prestação continuada da assis- In: White KL, Frenk J, Ordoñez Carceller C, Paganini
tência social devido à pessoa com deficiência e ao idoso JM, Starfield B, editores. Health Service Research: An
de que trata a Lei no 8.742, de 7 de dezembro de 1993, e Anthology. Washington: Pan American Health Organi-
a Lei nº 10.741, de 1º de outubro de 2003, acresce pará- zation; 1992. p. 842-855.
grafo ao art. 162 do Decreto no 3.048, de 6 de maio de 11. Andersen R, Newman JF. Societal and Individual De-
1999, e dá outras providências. Diário Oficial da União terminants of Medical Care Utilization in the Unit-
2007; 28 set. ed States. Milbank Mem Fund Q Health Soc 1973;
2. Brasil. Lei nº 12.470 de 31 de agosto de 2011. Altera os 51(1):95-124.
arts. 21 e 24 da Lei nº 8.212, de 24 de julho de 1991, 12. Olson M. The Logic of Collective Action. Cambridge:
que dispõe sobre o Plano de Custeio da Previdência Harvard University Press; 1965.
Social,para estabelecer alíquota diferenciada de con- 13. Elster J. The Cement of Society. Cambridge: Cambridge
tribuição para o microempreendedor individual e do University Press; 1989.
segurado facultativo sem renda própria que se dedique 14. Gillinson S. Why Cooperate? A Multi-Disciplinary Study
exclusivamente ao trabalho doméstico no âmbito de of Collective Action. London: Overseas Development
sua residência, desde que pertencente a família de baixa Institute; 2004.
renda. Diário Oficial da União 2011; 01 set. 15. Polski MM, Östrom E. An Institutional Framework for
3. Marsiglia MRG. Avaliação do Processo de Revisão e Policy Analysis and Design. Workshop in Political Theory
Proposta de Sistema de Monitoramento do Benefício de and Policy Analysis. Indiana University. Bloomington;
Prestação Continuada (BPC). Brasília: Secretaria de 1999. (Workshop Working Paper Series, nº W 98-27)
Avaliação e Gestão da Informação/SAGI, Ministério do 16. Ostrom E. Understanding Institutional Diversity. Princ-
Desenvolvimento Social e Combate à Fome; 2011. eton: Princeton University Press; 2005.
4. Diniz D, Medeiros M, Squinca D. Reflexões sobre a 17. Peters G. Managing horizontal government. The politics
versão em Português da Classificação Internacional de of coordination. RESEARCH PAPER No. 21 Canadian
Funcionalidade, Incapacidade e Saúde. Cad Saude Pu- Centre for Management Development. Canadian Cen-
blica 2007; 23(10):2507-2510. tre for Management Development. January 1998.
5. Bim MCS, Carvalho M, Murofuse NT. Análise dos mo- 18. Rantala R, Bortz M, Armada F. Intersectoral action:
delos de avaliação de requerentes ao beneficio de pres- local governments promoting health. Health Promot
tação continuada: 2006 a 2012. Katálisis 2015;18(1):22- Int. 2014; 29(Supl. 1):i92-102.
31. 19. Solar O, Irwin AA. Conceptual Framework for Action on
6. Guedes HHS, Fonseca GL, Abdo RSR, Donato SAS, the Social Determinants of Health. Geneva: World Heal-
Aguiar AT, Esteves EF. O novo modelo avaliativo do th Organization; 2010. (Discussion Paper, 2)
BPC: desafios, possibilidades ao serviço social. Tempo- 20. Henrique FCS. Intersetorialidade na implementação de
ralis 2013; 13(25):235-2597. programas das áreas de Segurança Alimentar e Nutricio-
7. Chaves MM. Avaliação da nova modalidade de concessão nal: um estudo sobre arranjos institucionais em municí-
do Benefício de Prestação Continuada (BPC) à pessoa pios de pequeno porte do estado da Bahia [tese]. Rio de
com deficiência com base na Classificação Internacional Janeiro: Escola Nacional de Saúde Pública; 2014.
de Funcionalidade, Incapacidade e Saúde (CIF). Brasília: 21. Hopkins M. Couture C, Moore E. Do heróico ao cotidia-
Secretaria de Avaliação e Gestão da Informação/SAGI, no: lições aprendidas na condução de projetos horizon-
Ministério do Desenvolvimento Social e Combate à tais. Brasília: ENAP; 2003. Cadernos ENAP, 24.
Fome; 2011.
8. Donabedian A. The assessment of need. In: Donabe-
dian A, editor. Aspects of Medical Care Administration.
Cambridge: Harvard University Press; 1973. p. 58-77.
9. Starfield B. Acessibilidade e primeiro contato: a ‘porta’.
In: Starfield B, organizador. Atenção primária – equi-
líbrio entre necessidades de saúde, serviços e tecnologia.
Brasília: Organização das Nações Unidas para a Educa- Article submitted 15/05/2017
ção, a Ciência e a Cultura, Ministério da Saúde; 2002. Approved 03/07/2017
p. 207-245. Final version submitted 25/08/2017