A relação público-privada na atenção ambulatorial de média e alta complexidade do Sistema Único de Saúde na região da Baixada Cuiabana - MT

Abstract

The overall purpose of the present thesis is to analyze the public-private relationship in the outpatient care of medium and high complexity in the Unified Health System (SUS), in the health region of Baixada Cuiabana, Mato Grosso. It is a study of quantitative and qualitative nature, which was developed in three stages. The first stage was based on secondary data from national databases and explored the network structure of outpatient care of medium and high complexity, the supply of its services, the approved value and the public and private participation. The second stage consisted of document survey and analysis, aiming to seize control and regulatory frameworks, adopted and implemented by the state of Mato Grosso and the city of Cuiabá, in the provision and monitoring of private / philanthropic services linked to SUS. The third stage consisted of conducting semi-structured interviews with key-informers, in order to apprehend the public and private relationship which pervades this type of care in the region. Descriptive statistics were utilized to explore the quantitative data, which were discussed in the light of literature. The qualitative exploration of documental basis and interviews occurred through content analysis, according to matrix analysis. The quantitative results indicated that, in Baixada Cuiabana, more than a half of the establishments providing ambulatory care within SUS are public and this situation is virtually reversed when talking about the Support Services for Diagnosis and Therapy (SADT). Such services are concentrated in Cuiabá and in the private / philanthropic sector regarding its distribution, ambulatory production and approved value. The qualitative empiric basis showed deficient macro and micro regulation: the first reflected in the virtual absence of strategic projects for the sector and low regulatory capacity of the state and of Cuiabá; the second is due to the nonexistence of an information system between the regulation centrals, suppliers and departments, even though during this research the Municipal Health Department was in the initial stages of implementation of SUS Regulation System – SISREG; discontinuity of processes due to successive changes in management; outdated tools for management planning; lack of appropriate monitoring of PPI (Integrated Agreed Schedule); faulty physical and staff structures of the regulatory complex; lack of reference and counter-reference systems in the state of Mato Grosso and in Cuiabá; outdated and incomplete contracts with the private / philanthropic suppliers and absence of protocols and work instructions. Such results indicate a complex situation in the public-private relationship, for, if on one hand Cuiabá concentrates the medium and high complexity ambulatory care, mainly in the private / philanthropic sector, on the other hand, there are major political and technical difficulties in planning, evaluating and monitoring within the involved departments, regarding this type of care. This context demonstrates that the private / philanthropic sector holds significant political and lobbying power over decisions within SUS, both in contract negotiation as well as concerning the privilege of ensuring provision of those better remunerated ambulatory procedures.