Equity and Local Government: Sao Paulo, Brazil

Author(s) Vera Coelho1
Affiliation(s) Citizenship, Health and Development Group , Brazilian Centre of Analysis and Planning , Sao Paulo, Brazil.
Country - ies of focus Brazil
Relevant to the conference tracks Health Systems
Summary Brazil has established a nationwide health system (SUS) aimed at ensuring universal access and has made enormous progress towards this goal over the past two decades. However, a number of studies have shown that certain vulnerable groups often do not have effective access to the services they need. The study analyzes the evolution of the supply and consumption of public healthcare services within the municipality of São Paulo between 2000 and 2011. The results show that there has been equity gains that favored groups living in areas that present the worst socio-economic indices. The paper discusses how municipal health policies and politics helped to guarantee these achievements.
Background During the 1990’s a new governance structure was forged and contracts were initiated between the federal, state and municipal governments, which defined responsibilities and transparent financing rules for the implementation of the national health policy. At that time the effective institutionalization of the health conferences, a national health council, and the health councils in all twenty-six states and in nearly all of the 5,561 municipalities also took place. Today the national government has an important role in regulating and financing health services, while state and municipal governments are responsible for delivering services and allocating supplementary funding. One major challenge facing the SUS is how to increase the system’s equity as the provision of services is still skewed in favor of wealthier regions and citizens. In particular, the study focus on the difficulties posed in tackling internal equity gaps in mega cities as, despite the fact that these are highly unequal areas, the national policy only focuses on inequalities between regions, states and municipalities. The study explores how municipal politics favored the adoption of policies that helped in guaranteeing a more equitable distribution of public health services in the mega city of Sao Paulo.
Objectives The study evaluates the redistributive efficiency of the Sao Paulo municipal policies’ adopted between 2001 and 2011. The period covers three municipal terms. The study: 1) follows the distribution of public health services – equipment and service supply - in all the 31 sub-municipalities between 2001 and 2011; 2) describes the health policies implemented by each of the three administrations and explores the rationale for its adoption; 3) tests the plausibility of the assumption that relates, on one hand, the coupled presence of competitive election for local office and citizen participation and, on the other hand, the adoption of innovations that favored greater equity. The main questions we planned to answer were: Did the gap across areas with the highest and lowest Intra-Municipal Development Index narrow during the period? Can we identify how the different strategies adopted by the municipal government in each term worked to reduce or widen this gap? What was the role played by local politics in favoring the adoption of these strategies?
Methodology The analyses gauge the effect of municipal health policies on indicators of access to public health services. The study was organized in three steps. First, a geographic Information System (GIS) was organized. It contains data from the years 2000 to 2011 on per capita primary appointments of a given submunicipality, the rate of hospital admission per 10.000 residents of a given submunicipality; age, income, and educational level of the submunicipalites’ resident population and the proportion of SUS users and out-of-pocket or private insurance users. The SUS-user is a citizen without a private health insurance, who uses the public health system, which in São Paulo’s case representes 48% of the total population. For primary consultations there is no information to allow for identification of the beneficiary for a given appointment and we assumed a plausible premise that this kind of service tends to be produced in a decentralized fashion and consumed locally. For hospital admissons we worked with the Hospital Admission Authorization (AIH), the means through which healthcare service providers in Brazil are reimbursed. AIH records indicate the zip code of those who used the SUS service which allows for mapping of the consumption of hospitalizations in the sub-municipalities areas. Equity gains have been estimated as the difference between each outcome in the sub-municipalities areas, which are in the highest socioeconomic quartile compared to the lowest quartile. The sources are CENSUS (IBGE) and Data SUS (Ministry of Health).In the second step a structured questionnaire with closed and semi-open questions was applied to health councilors, service providers and municipal public officials. Moreover, we collected data provided to official media for public announcements and mass media. The analysis of these materials helped in understanding the political context and the decisions made by each of the three administrations.In the third step we analyzed the distribution of health units and basic appointments as well as hospital admissions and sought to locate turning points that favored the equity gains identified in the first step. Once we identified these turning points we investigated the relationship between them and the policy decisions made by each of the three administrations, which were identified in the second step.
Results Despite the fact that the SUS population was concentrated in the outskirts, in 2001 in the city of Sao Paulo equipment and services were concentrated in the central and oldest areas of the city of Sao Paulo. This meant that the populations who lived in areas with better socioeconomic indicators were privileged compared to populations living in the outskirts of the city. In this sense, it is important to note that the differences in distribution measured in the present work are between the poor that live in different areas of the city, rather than between poor and non-poor as such. The bias in favor of central areas was partially reversed in more recent years and this was made possible through heavy investment in infrastructure. The average number of basic health units per 20,000 SUS users increased from 0.79 to 1.42, and there was considerable progress in the distribution of these equipments to areas in the outskirts of the city. The implementation of new hospitals has privileged poorer areas, as can be noted by the fact that four out of five new hospitals built in this period were in areas among the 10 sub-municipalities with the lowest Human Development Index (MHDI) in the city. Along with this expansion there was a shift in the distribution of hospital beds: in 2001 the 9 sub-municipalities with the smallest MHDI supplied 5.75% of the public hospital beds in the municipality, while 10 years later this percentage had increased to 13.48%. It should also be noted that, in 2010, hospitalizations were 61.9% higher among SUS users residing in the first quartile (the poorest) and were only 13.8% higher among fourth quartile residents (the richest).The rate of primary appointments increased by 154.7% between 2001 and 2010, with the average rate of basic appointments per SUS user per year going from 1.28 to 3.26. From 2002 to 2006 the standard deviation in the distribution of these appointment between submunicipalities decreased from 0.93 to 0.66.The data collected and analyzed by the study clearly shows that there was significant expansion in the supply as well in the consumption of services in the regions that presented the worst socio-economic and health indicators. An analysis of the distribution of these resources also showed that we now have a more equitable distribution pattern of public health services between locations with a reduction in the geographic inequalities hindering access to the public health system.
Conclusion The results described in the preceding section may seem expected, after all, the distribution of public health services was and still is biased towards wealthier areas and the correction of this situation is the most logical step. However, this is a striking result given how difficult it is to reverse this tendency as attested by the findings of a number of studies in different parts of the world, which indicate that the richest tend to persistently benefit more than the poorest from public spending on health (World Bank 2003; Liu, Hotchkiss and Bose 2007). The guidelines and programs established by the Brazilian Ministry of Health starting in the 1990s guaranteed that new resources reached the municipality. The simple use of these resources, replicating the distributive profile of the pre-existing equipment could, however, have easily led to a deepening of existing inequalities. As seen in the previous section, this was not what happened. From 2001, municipal managers began to take on a major role in proactively coordinating municipal policy and prioritizing those areas with higher populations of SUS users, which are the poorest areas and those with worse health indicators. The analysis suggests that the equity gains reported in the study happened trough cycles of micro and macro politics that reinforced each other. The micro cycles were lead by active local health councils which used political mobilization and contacts to pressure the municipal health secretariat for more resources. The macro cycles involved political projects and efforts by both the Workers' Party (PT), that held municipal office from 2001 until 2004, and the Brazilian Social Democracy Party (PSDB), which entered office in 2005. The equity gains made possible by the macro cycles were assured by the use of technical criteria to make sure that the new resources made available for basic health were distributed in a manner that would serve the population living in the municipality in a more equitable way. As it is described in detail in the study, these two dynamics, fed by political competition between PT and PSDB, allows for an explanation of the adoption of many of the policies that forged the distributive results described in the previous section.

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