Fatores determinantes da alocação de recursos na atenção primária à saúde de pequenos municípios: uma construção microinstitucional

Abstract

The latest public health policies have set Primary Health Care (PHC) as an entrance to health care network, causing changes in the allocation of resources in this sector, including in small municipalities. From a neoinstitucional perspective, this dissertation aims to answer thefollowing question: how do actors and institutions influence the resource allocation of primary care in small municipalities? To answer this question, this study aimed to identify and understand determinants of primary care allocation of resources and their interactions, in smallmunicipalities of Minas Gerais, from the perspective of New Institutional Theory. First, this study performed a qualitative analysis in nine municipalities from a micro-region of health in Minas Gerais State. This analysis included eleven focus groups, six interviews and two semistructured questionnaires, including ninety-four professionals and health managers. To substantiate these analyzes, this study added other sources of evidence such as non-participant observations, photographs and documents from Secretary State of Health of Minas Gerais andfrom Ministry of Health. Through conventional content analysis, eight categories showed important phenomena that influence the allocation of resources in primary care of these municipalities, all derived from daily processes of interaction among population, health professionals and managers. Some activities of PHC are still in the legitimation process that depends on the validity of actors and institutions at different institutional levels. The main phenomena observed in the presented categories were the intervention of politicians, professional groups and the private sector, as well as logistics management and health networkintegration. Moreover, this study carried out 238 (two hundred thirty eight) structured questionnaires to professionals and local health managers in the same micro-region. By the technique of exploratory factor analysis, this study found five factors that underlined the importance of the principles and guidelines of PHC, management, planning, training, evaluation and control of material and human resources. In addition, this study incorporated a set of fixed effect panels to understand impacts of municipal spending on health in 853 (eight hundred fifty three) municipalities in the state of Minas Gerais from 2004 to 2013. Two chapters explain the health spending analyses. The first one examined the impact of health expenditure on the variation of structure, processes and results of PHC and the second one examined the impact on ambulatory care sensitive conditions (ACSC). Results showed that government has increased financial allocation of municipal resources in health care during the reporting period, placing municipalities as one of entities with greater responsibility for the health system. In addition, results show that socioeconomic factors, sanitation and specific groups of individuals had greater effects than those found for municipal health expenses. In conclusion, the methods applied in this dissertation led to a convergence of results, suggesting the existence of factors at different institutional levels, which influence the allocation of resources in PHC and, consequently, influence the development of the entire health network in Minas Gerais. Among the main resource allocation determinants of PHC, this study highlights the agencies of embedded actors, hospital history, private sector, medical corporatism, politics, municipal management, infrastructure and sanitation.