Arranjos institucionais de coordenação e cooperação intergovernamental no SUS: a descentralização da assistência farmacêutica básica

Abstract

This is a descriptive case study on institutional arrangements for coordination and cooperation in brazilian health policy, which takes as its case the decentralization of pharmaceutical assistance in primary health care. Despite broadening access to basic medicines, this movement has also produced contradictory effects, expressed by a pattern of inequality in medicines supply among municipalities. It is argued that intergovernmental cooperation at the subnational level can promote positive effects in this paradoxical situation, producing incremental gains in the coordination of medicines policy. The study seeks to describe the decentralized institutional arrangements for the procurement and distribution of medicines for primary health care and to patterns of cooperation between states and municipalities. The methodological course was based on: a bibliographical review on the institutional frameworks of the national medicines policy; and a documentary analysis of executive summaries of intergovernment meetings at the national level and on current state agreements on the execution and financing of the program. It was observed that the topic of cooperation between subnational levels for the procurement and distribution of essencial medicines had little relevance in the national debates carried out along the medicines policy trajectory. In addition, it was verified the dominance of a totally decentralized design in the municipality in the majority of states, either in the management of financial resources or in the execution of the processes of procurement and distribution of medicines. It was also identified institutional mechanisms of cooperation practiced by subnational levels: state price registration, joint purchase by consortium and public production of medicines. The findings of this study suggest the incipient use of intergovernmental cooperation strategies for procurement and distribution of medicines for primary health care in Brazil. The arrangements adopted in the states, where high decentralization and low coordination and cooperation predominate, support the perception of a paradoxical situation that involves the universalization of pharmaceutical assistance and its high potential for fragmentation and inequity. The mapped situation suggests an absence of the development of concrete and innovative cooperative strategies in relation to the processes of procurement and distribution of medicines for primary health care in the country.