Government-academia cooperation in the Brazilian National Health System: an analysis of the National Program for Access and Quality Improvement in Primary Care

Abstract

This study analyzes the construction of institutional cooperation between the Brazilian Ministry of Health and academic institutions to develop the National Program for Access and Quality Improvement in Primary Care in the Brazilian National Health System (Sistema Único de Saúde - SUS). This qualitative research is based on a case study on this kind of cooperation, which carried out documental analysis and interviews with key actors from the Ministry of Health and academia. The political-institutional context of the federal government and the Ministry of Health in 2011 favored a greater opening to the theme of primary care and health evaluation, and a closeness to academia. This institutional cooperation is the result of a historical process where previous initiatives in the field of public health have connected public and academic managers interested in the development of SUS. This study contributes to the debate about the cooperation between government agencies and academia in implementing public health policies in Brazil.

Keywords:
public health policies; unified health system; primary health care; schools; historical neoinstitutionalism

Resumo

Este estudo analisa a construção da cooperação institucional entre o Ministério da Saúde e instituições acadêmicas para o desenvolvimento do Programa de Melhoria do Acesso e da Qualidade na Atenção Básica do Sistema Único de saúde, à luz do neoinstitucionalismo histórico. Esta pesquisa qualitativa baseia-se em um estudo de caso sobre essa cooperação, que realizou análise documental e entrevistas com atores-chave do Ministério da Saúde e da academia. O contexto político-institucional do Governo Federal e do Ministério da Saúde, em 2011, favoreceu maior abertura para o tema da atenção básica e da avaliação e a aproximação com a academia. Essa cooperação institucional resulta de um processo histórico cujas iniciativas precedentes no campo da saúde pública conectaram gestores públicos e acadêmicos com interesse na evolução do Sistema Único de Saúde. Este estudo contribui para o debate acerca da cooperação entre órgãos governamentais e a academia na implementação das políticas públicas de saúde no Brasil.

Palavras-chave:
políticas públicas de saúde; sistema único de saúde; atenção primária à saúde; instituições acadêmicas; neoinstitucionalismo histórico

Resumen

Este estudio analiza la construcción de la cooperación institucional entre el Ministerio de Salud e instituciones académicas para el desarrollo del Programa de Mejora del Acceso y la Calidad en la Atención Primaria del Sistema Único de Salud, a la luz del neoinstitucionalismo histórico. Esta investigación cualitativa se basa en un estudio de caso sobre esta cooperación, que realizó análisis documentales y entrevistas con actores clave del Ministerio de Salud y la academia. El contexto político-institucional del Gobierno Federal y del Ministerio de Salud en 2011 propició una mayor apertura al tema de la atención primaria y la evaluación de la salud, además del acercamiento a la academia. Esta cooperación institucional es el resultado de un proceso histórico cuyas iniciativas previas en el campo de la salud pública han conectado a gestores públicos y académicos con el interés en el desarrollo del Sistema Único de Salud. Este estudio contribuye al debate sobre la cooperación entre las agencias gubernamentales y la academia en la implementación de políticas públicas de salud en Brasil.

Palabras clave:
políticas públicas de salud; sistema único de salud; atención primaria de salud; instituciones académicas; neoinstitucionalismo histórico

1. INTRODUCTION

In 2011, the Ministry of Health (MS) created the National Program for Improving Access and Quality of Primary Care (PMAQ-AB), with the objective of expanding the responsiveness of this level of care of the Brazilian Unified Health System (SUS) to the health problems of the country (Cavalcanti, Fernandez, & Gurgel, 2021; Pinto, A. N. Sousa, & Ferla, 2014; A. N. Sousa, 2018). The program established formal performance compensation mechanisms linked to nationally standardized evaluation procedures (Pinto et al., 2014; A. N. Sousa, 2018). For the execution of part of the program’s evaluation process, the MS signed institutional cooperation with a set of Brazilian teaching and research institutions (IEPs) (Cavalcanti & Fernandez, 2020). However, in 2019, after institutional change in the Federal Government, the PMAQ-AB and government-academia cooperation were terminated (Cavalcanti et al., 2021). This aspect will not be the focus of this research, as it requires a particular in-depth study for a better understanding of this process.

Under the influence of public sector reform processes, more specifically in the context of the New Public Administration, large health systems in the world have focused on strategies that result in various possibilities for cooperation between government agencies and IEPs, with a view to strengthening institutional relations to achieve better results of services provided to the population (Abrucio, 2007). This political-institutional phenomenon has been the object of scientific research in recent years to better understand the nature and scope of this approach. In Brazil, there is still no vast scientific literature that investigates government-academia cooperation initiatives for the implementation of government policies/programs in SUS.

Thus, to contribute to the densification of knowledge on the subject, this study analyzes the process of building government-academia institutional cooperation for the development of the PMAQ-AB, in the light of historical neo-institutionalism (NH), in order to identify historical legacies, conjunctural factors, interests, and actions of national actors that conditioned decisions towards this cooperation as a privileged way to implement the program.

The article is organized into four sections, in addition to this introduction and conclusion. The second section addresses the theoretical contributions of the NH as a reference for the analysis of the central aspects of the construction of this cooperation; the third deals with the methodology of the study, presenting the techniques applied, and the approach adopted; the fourth section presents the results of the research based on analytical categories outlined; finally, in the conclusion, it interacts with the scientific literature.

2. HISTORICAL NEO-INSTITUTIONALISM AND ITS APPLICATION IN THE CASE OF GOVERNMENT-ACCADEMIA COOPERATION IN PMAQ-AB

Neo-institutionalism is a currently important theoretical framework for political analysis; however, it does not consist of a unified current of thought since it covers theorists of disciplinary origins and diverse hues. As an effect, there are distinct models of analysis that emerged from 1980 that claim this designation. The collection of neo-institutionalist theories converges on the argument that institutions comprise the central vector of analysis for explaining political and social processes (Hall & Taylor, 2003).

According to North (2018), neo-institutionalism emphasizes that the struggle for power and resources between social groups is the core of public policy formulation and that institutions configure the “rules of the game” in society, imposing constraints that shape human interaction in the social environment and in political life. This struggle is mediated by political and economic institutions that take public policies in a certain direction and privilege some groups over others, although institutions alone do not determine all results.

In the specialized literature, most authors consider three most prominent neo-institutionalist strands: rational (NER), sociological (NS) and historical choice (Hall & Taylor, 2003). Each of them reveals the important aspects of the behavior of social and political actors and the influence that institutions can have on them, but they are distinguished by how they are understood and how they explain the processes of origin and the change of institutions. In summary, NER emphasizes the calculating behavior of actors to maximize their interests within the limits imposed by institutions, which establish the context of norms and rules. The NH focuses on the historical evolution of political institutions, associating them with the rules or conventions issued by formal organizations that affect actors’ behavior. The NS understands political institutions as socially constituted and culturally shaped, with political agents acting according to socially appropriate modes.

From the point of view of this research, the historical framework was adopted to analyze an initiative of academic relevance and for public health policy: the construction of institutional cooperation between the MS and the IEPs for the implementation of the PMAQ-AB. It is understood that the assumptions of this approach are useful to understand the strategies of state action to enable the program, given the political-institutional characteristics of the time, considering the role of institutions and actors in the formulation, decision, and implementation of public policies, in historical contexts that demarcate the trajectory of these government initiatives in the SUS.

It should be emphasized, then, that the NH considers, in the analyses, the contribution of institutions, while valuing other factors such as actors, their interests and strategic actions (Immergut, 1998); socioeconomic development and ideas (Hall & Taylor, 2003). In this conception, institutions correspond to the formal and informal rules inherent in the organizational structure of the political community that mediate relations between actors and provide them with moral and cognitive models that allow interpretations and actions, while influencing their preferences, identity, and objectives (Hall & Taylor, 2003; Pierson, 2000, 2004).

According to Immergut (1998), political decisions are born in a complex environment, in which political and social processes are influenced by institutional factors and by interests, worldviews, and generally conflicting ideas of actors, with different capacities to intervene in politics (Hall & Taylor, 2003). Thus, the processes undertaken by institutions and actors with combined decision-making power are capable of directing the strategies adopted within the scope of public policies (Chagas, 2016), which conditions their path dependence as a result of social causality (Pierson, 2000, 2004). Without conceptual unanimity, the path dependency assumes that, to discover the logic of the real world, it is necessary to understand the details based on which the current point was reached (Bernardi, 2012). This requires observing the sequence in which events or processes occur and their influence on outcomes that unfold over time (Mahoney, 2000).

It characterizes the nature of path dependency, the notion that choices that occur at a given time condition later options while restricting so many others (Immergut, 1998; Mahoney, 2000; Pierson, 2000, 2004). But history matters not only because of the learning that the past can provide; it serves to understand that the choices made at the moments of construction of institutions or policies exert an effect of embarrassment on the future, through the continuity of the institutions of a society (North, 2018).

This central premise of the historical-institutional approach points to an inertial trend of institutions, a factor that blocks or hinders subsequent changes. Once a path is taken, the political and economic costs of changing it are usually high (Immergut, 1998; Pierson, 2000, 2004). However, understanding the trajectory of institutions and public policies also involves recognizing that the environment is marked by sequences and contingencies, and it is possible to identify the institutional factors related to them (Immergut, 1998).

Historical contingencies emphasize the elements of rupture, in which accidents of opportunity and circumstance determine history, that is, they are capable of causing changes of path. Therefore, institutions matter from the perspective of changing or maintaining the status quo and should be analyzed in association with historical facts, in a longitudinal sequence. In this sense, in institutional historical studies, the path dependence stands out as a category that emphasizes institutional legacies and the elements that contribute to the development of policy or the program, which can be based on the processes that cause incremental changes in trajectory and shock that characterize the critical moment (Chagas, 2016; Fernandes & Wilson, 2013; A. C. A. Sousa & Costa, 2013).

3. METHODOLOGY

This qualitative research, based on a case study, was developed based on research methods, document analysis, and interviews. In doing so, it sought to use multiple sources of evidence to develop a data triangulation process, aiming at increasing the reliability and validity of the researched data (Yin, 2015).

In the first stage of the documentary analysis, official documents on the PMAQ-AB were selected, published from July 2011 to July 2019, on the website of the Secretariat of Primary Health Care of the MS (Ministry of Health, 2011a, 2011b, 2015, 2017a, 2017b, 2018). The second stage of the documentary analysis aimed to verify the financial resources corresponding to the execution of the external evaluation (AE). Thus, the amounts transferred to the IEPs between 2012 and 2019 linked to the PMAQ-AB were requested from the MS. The data were structured and analyzed with the aid of the Microsoft Excel® Program. The results will be presented in absolute and average values, which represent the costs of operationalization of the external evaluation. Finally, information about the health authorities of the MS was collected on the Lattes platform.

Preliminary analyses of the documents showed a lack of detail of the political-institutional processes related to institutional cooperation. It was then chosen to use semi-structured interviews with key actors involved in the decision-making process about the conduct of the PMAQ-AB within the scope of cooperation, considering that they are individuals with fundamental information about this process. In the interviews, a specific script was used for each interviewee profile. The key actors of the MS involved people with the position of leader and, from the IEPs, representatives of the “main institutions”, who participated in the initial debates for the first cycle of the PMAQ-AB (Cavalcanti & Fernandez, 2020).

A total of seven interviews were conducted remotely, from March to July 2020, with key actors: three from the MS and four from the IEPs, being interrupted when redundancy of information was found and the theoretical saturation point was reached (Minayo, 2014). The data approach was based on content analysis (Bardin, 2015), in order to unveil the processes that involved the construction of institutional cooperation, still little known. In the pre-analysis, the documents obtained were read, aiming to assist in the choice of those that would be submitted to analysis and in the elaboration of indicators. The exploration of the material sought to reveal characteristics of the content, through categories of analysis based on the NH, according to Pereira’s proposal (2014): the political-institutional dimension and the historical-institutional dimension. But it also emerged from the corpus of research. These are: Federal Government: political-institutional context and priority agenda for AB; alternative ways to implement the PMAQ-AB; actors: conflicts and interests about the PMAQ-AB; expansion of the institutional capacity of the MS. Finally, the evidence found supported the interpretation of the content and understanding of the meanings.

4. RESULTS

4.1. Federal Government: political-institutional context and priority agenda for AB

In 2010, Dilma Rousseff was elected, which represented the third consecutive victory of the Workers’ Party (PT) in the presidential election and the continuity of the governments of President Luís Inácio Lula da Silva (Lula). In 2011, in the inaugural speech, the president declared that the SUS would be a government priority, in addition to the effort to monitor the quality of services and respect for the user (Ministry of Health, 2011a).

In MS, the main positions were held by staff affiliated with or close to the PT and by the center-left coalition (Machado, Lima, & Baptista, 2017). Many of these individuals acted as leaders or representative entities of the SUS, had links with public universities or participation in social movements (health movement and student movement, especially in medicine). The political-academic trajectory of a significant part of the MS management team had a similar origin - it showed previous links and sharing of objectives, ideas, and values.

The doctor Alexandre Padilha, former Minister of Institutional Relations and former Director of Indigenous Health of the National Health Foundation of the Lula government was appointed Minister of Health. In the inaugural speech, Padilha reaffirmed the government’s priorities for health, including the commitment to the consolidation of AB in a country with such diverse realities; emphasized the need to have a national map of health equipment and invited managers, advisors, and academics to a debate on solutions to SUS problems. At the time, he mentioned the president of the Brazilian Association of Collective Health (ABRASCO), at the time, Luís Facchini, to involve the entity in the fulfillment of these priorities (Ministry of Health, 2011b).

In the Secretariat of Health Care and in the Department of Primary Care (DAB), bodies responsible for the management of AB in the MS, were the doctors Helvécio Miranda Magalhães Júnior and Hêider Pinto. The first was Municipal Secretary of Health and Planning, Budget, and Information in Belo Horizonte (Minas Gerais) and president of the National Council of Municipal Health Secretaries. The second was director of AB at the State Department of Health of Bahia and the State Foundation for Family Health in that state.

After meetings between the senior staff of the MS, the Presidency of the Republic and the Civil House, AB was announced as a priority in SUS. Thus, the conditioning challenges for the development of the area that should be the focus of action through government initiatives were listed, one of the main problems being funding.

Since we are talking about history and important actors, there has always been an expectation over years and especially from the government of former President Lula, that performance evaluation could be an important element to improve the quality of service, facilitate access, improve supply [...]. When Dilma took over the government, she asked Minister Padilha and the director of AB, Hêider Pinto, to think of a way to reward [financially] health teams due to performance, so there was a proposal to do the PMAQ-AB (E-6).

The PMAQ-AB, disclosed as the main strategy for inducing changes in the functioning of basic health units (UBS), proposed a set of initiatives for qualification, monitoring, and evaluation of health teams.

The leaders of the MS considered it insufficient to perform self-assessment, analysis of indicators and verification of users because of the limitations of each of these methods. Therefore, they decided to carry out an on-site evaluation, called external evaluation, in the form of a standardized national research to check a set of variables (E-1).

There was an expectation of the government to evaluate the UBS not only for the payment for performance of the PMAQ-AB, but to guide investments in infrastructure, through the UBS Physical Structure Requalification Program (Requalifica UBS). Thus, in the policy formulation process, a “UBS Census” was integrated into the external evaluation of the PMAQ-AB, according to the following evidence.

In the negotiation of AB agendas, the main interest of the president was to know the situation of the UBS of the country due to the Requalifica UBS, so it was decided to carry out the first UBS Census (E-3).

There was an expectation of very great investment from the Federal Government to build, reform and expand the UBS [...]. Dilma Rousseff wanted us to know the physical reality of all health units in Brazil, so that this would guide the investment policy in the infrastructure of services, through the Requalifica UBS, which was connected to the PMAQ-AB (E-6).

4.2. Alternative ways to implement the PMAQ-AB

According to the interviewees, three possibilities were identified for the execution of the external evaluation in the national territory: through the Brazilian Institute of Geography and Statistics (IBGE), private research institutes (IBOPE, Datafolha, Vox Populi) or universities.

Initially, meetings were held with researchers who had been studying AB in the country for a longer time with relevant research, with the objective of consulting them on the feasibility of carrying out a process of data collection of the magnitude that the PMAQ-AB intended. Associated with this, the MS team contacted non-academic data collection institutions: private institutes and the IBGE (E-1).

We identified some on-site evaluations and research that had been done and that were happening [...]. There was the group of the Primary Health Care Research Network (APS Network), from ABRASCO, which we called to talk about the proposal of the PMAQ-AB, and if the universities were willing to build an external evaluation. There was another idea in the government that was to make this assessment using the research institutes, because the government was thinking a lot about opinion (MS-3).

The partnership with institutes and IBGE became unfeasible due to the financial resources to be used or the time for the execution of the research, which would affect the implementation of the program, as evidenced by the following statement:

With research institutes, the cost would be very high, although the delivery time would be faster; with IBGE it was exactly the opposite: the costs were lower but would have to enter a waiting list of the research and collections that the IBGE did, which would make the political time of the program unfeasible (E-1).

According to the interviewees, the most viable alternative was the establishment of partnerships with the IEPs. The following statements detail the reasons for such a choice.

In early 2011, it was necessary to establish a set of political articulations to support the program. One aspect of the external evaluation comprised the academic dimension, although the PMAQ-AB was not based on stricto sensu academic evaluation research, it was necessary to legitimize the information collected based on an evaluation process [...]. The method of choice was based on the performance, evaluation, and political legitimacy of the data collection process, in view of possible disputes about the applied techniques. Having the seal of renowned institutions [...] that, in the Brazilian reality, have a lot of academic respect, was important in this sense [...]. We can say that the external evaluation of the PMAQ-AB, although not having a stricto sensu academic purpose, guaranteed this cooperation with universities (E-1).

The best way was to establish partnerships with universities, given the nature of the process, which needed knowledge about the area of health, collective health, and the work process of health teams [...], due to the expertise of IEPs in evaluation processes in the area, the capillarity of these institutions in Brazilian states (most public, federal, or state) and the most advantageous cost. Therefore, the MS team sought to show the Presidency of the Republic and the Civil House that cooperation with the IEPs would be the best option (E-3).

The dimension of legitimacy of the evaluation process was emphasized by the interviewees:

Of course, it legitimizes a proposal when academic institutions participate in the process [...]. The gain that the MS had, certainly, was the support of many researchers [...]. From a technical and political point of view, this also gave authenticity to the proposal (E-5).

Historical legacies and conjunctural factors were evidenced, as well as the interests, ideas, and objectives of the actors that influenced the establishment of this government-academia cooperation in SUS. According to the interviewees, this collaboration is part of a historical process of approximation between the MS and the IEPs to assist in the production of AB evaluation studies related to the challenges of SUS, as evidenced by the following excerpt:

As I have been involved in this process for a long time, I understand this partnership in terms of historical context [...]. Some procedures contributed to develop and intensify cooperation between academic institutions and SUS, such as the creation of SUS and, above all, Family Health; DAB-MS Monitoring and Evaluation Coordination (CGAA), which expanded efforts to institutionalize evaluation in SUS [...]; the Baseline Studies of the Family Health Expansion and Consolidation Program; Quality Improvement Assessment (AMQ) and many other initiatives. The articulated action of the MS with the National Council for Scientific and Technological Development, through the Secretariat of Science, Technology and Strategic Inputs, has greatly increased cooperation between research groups and academic institutions with SUS (E-6).

The PMAQ-AB contributed a lot to the incorporation of a culture of monitoring and evaluation, since it was based on previous initiatives, such as the Family Health Expansion and Consolidation Project, and the family health qualification process (E-2).

Since 1994, this university has been involved with academic production linked to the challenges of SUS and in relation to AB [...] and in partnership with DAB-MS (E-5).

The presence of managers, throughout the Lula and Dilma governments in the MS, close to the academia and active in social mobilization movements, was a facilitating factor for cooperation with the IEPs with a view to enabling the implementation of the program.

There has always been a history of cooperation with the MS, since the first government of former President Lula until that moment (2011), despite the change of leadership in the MS [...] Padilha, Hêider, Helvécio and many other colleagues in the Secretariat of Labor Management and Health Education and elsewhere in the MS had common histories with universities. Part of these universities participated in the effort to evaluate the movement of the National Interinstitutional Commission for the Evaluation of Medical Education (CINAEM) [...]. Even before, for example, in 2003, when the CGAA/DAB-MS was created, Eronildo (Felisberto) was a university professor. [...] So, there was always this permeability in MS. Many managers of the Ministry of Health who led actions were graduates from universities or were still linked to them (E-6).

According to E-6, “everything is socially determined”, but, in his conception, “it is natural that the MS, when it wants to produce knowledge, associates with universities, even more considering the objective of the policy that was intended to be implemented and the financial incentive based on evaluation”.

For E-3, “the option for IEPs sought to establish a closer relationship with existing knowledge production spaces and support for the improvement of public policy”. Although most interviewees emphasized the possibility of expanding the production of knowledge and accumulating intelligence in evaluative research in the health field as a motivator for choosing IEPs, the interviewee E-1 revealed that this “[...] was not an objective of the program. If you check the initial documentation of the PMAQ-AB, there was no intention to support the research agenda in AB”.

According to E-5, there was, on the part of the academia,

[...] the interest in contributing to the production of scientific knowledge for the development of the SUS [...]. The research focuses on its use, but has a position as well. It is the defense position of the system, without waiving the methodological rigor necessary to develop evaluative studies.

In the vision of E-4,

[...] the participation of the university was defined in the context of an institutional policy to strengthen links between education and the SUS in a broader way, overcoming the dominant relationship with the teaching hospital and articulating territorial and priority strategies for health education.

4.3. Actors: conflicts and interests about the PMAQ-AB

According to the interviewees, at the beginning of the government of President Dilma, the debate on the priorities of public health policy in the Federal Government included high-level leaders of the MS and the central nucleus of the government, who decided on the prioritization of AB in the government agenda. During the process of defining the strategies for the implementation of the PMAQ-AB, more specifically the operationalization of the external evaluation, the debate was concentrated on the MS and included other actors from governmental and non-governmental entities.

The interviewees highlighted the role of the APS Network in this process of building cooperation, which, for almost a decade, has been working with the MS to support and carry out evaluative research in AB. In the PMAQ-AB, the APS Network was elected as the main point of dialogue between the partners and the mobilization of several research groups in the country: “Cooperation for the PMAQ-AB was structured based on the actions of the APS Network, which acted in the representation of universities before the DAB-MS” (E-7). According to E-4, “this project for universities was born in the APS Network, based on a political-institutional movement of these universities, which found space for debate in the APS Network”.

For E-7, “this process was important to articulate other IEPs that, historically, did not participate in the production of research and development of field work”. In his perspective, this mobilization took place with the debate on external evaluation: “[...] several groups already participating in the APS Network were getting organized; other institutions approached, until they formed a large group. Thus, this research network has greatly expanded and extrapolated the limits of the APS Network, creating other nuclei”.

However, the political dispute between the groups and the technique for the methodological procedures associated with the evaluation of the PMAQ-AB, mainly in the definition of the evaluation instrument, determined the participation of the actors/IEPs in the cooperation. “The performance of members linked to the APS Network was not unanimous, since many colleagues were critical of PMAQ-AB” (E-5).

At the beginning of the PMAQ-AB, there was resistance from some sanitarians, who had prepared the AMQ, but, after explanations, they were not against the program. The only opposition was from the Brazilian Society of Family and Community Medicine, which defended the use of the Primary Care Assessment Tool to evaluate the AB, validated by members of the entity, and claimed the differentiated payment for the Family Doctor [...]. This group did not join the PMAQ-AB because it was part of a political group that, in a way, was an opponent of those who supported the PMAQ-AB (E-3).

Some researchers did not support the project because they have another epistemic perspective or academic trajectory [...]. Certain members of the APS Network, in 2011, participated in the initial discussion agendas for the formulation of the program and were invited to build the external evaluation process and act on it, but did not accept it. They proposed the use of PCATool as an evaluation tool [...]. As this did not happen, they refused to participate (E-1).

4.4. Expansion of the institutional capacity of the Ministry of Health

In the process of political articulation and definition of the object of institutional cooperation, in addition to the external evaluation of the PMAQ-AB, a census of the UBSs was negotiated with the IEPs. However, the resolution regarding the execution of the first one by the IEPs was after the decision of the external evaluation, according to the following statements: “The decision of the execution of the census by the IEPs was later because it took longer to be sure that the universities would be able to carry out the census” (E-3). “Finally, the researchers said they were able to carry out the census, as they would already go to the municipalities to do the external evaluation” (E-1). “[...] Requalifica was a program that ran parallel to PMAQ-AB [...]. The evaluations of the programs have merged over the years” (E-6).

The cooperation was formalized by means of covenants for the transfer of financial resources to the IEPs, aiming at the execution of the external evaluation of the PMAQ-AB (which integrated the census) in approximately 40 thousand UBS/teams in the country, in the different political-institutional contexts of the more than 5 thousand Brazilian municipalities, in different periods.

For the formalization of cooperation in the federal administrative sphere, the MS team discussed internally how to institutionalize this process with the IEPs [...] it could not be through public notices for the convocation of universities because it would take too much time [...] both to legitimize and to ensure compliance with the rules of establishment of cooperation, it was decided to do it through a debate with the APS Network, which already existed (E-1).

Thus, the rite of elaboration of the project was followed, with the delineation of the scope of the research and forecast of financial resources, aiming to guarantee the participation of IEPs in the discussion forums for the planning of actions; the purchase of equipment, material, and supplies, including tablets; the constitution of a research team and the execution of the fieldwork itself in the municipalities.

According to Box 1, the implementation of the PMAQ-AB has been converted into three programmatic cycles. In the first (from October 2011 to January 2013), the MS signed a covenant with six IEPs; in the second (from February 2013 to September 2015), with seven; in the third (from October 2015 to May 2019), with nine. The total cost of the external evaluation was, on average, BRL 1,411.69 per UBS, to apply the unit’s verification questionnaire and interviews with teams and users, considering all the cycles of the program. During these cycles, the number of teams increased progressively, especially after the program was universalized in the second cycle. Therefore, the financial resources transferred to the IEPs were increased and there was an adjustment in the financial resources to ensure equivalence between the IEPs, considering access issues, new distribution of UBS/visited teams and acquisition of technological equipment.

BOX 1
TOTAL UBS/TEAMS/USERS AND FINANCIAL RESOURCES TRANSFERRED TO THE IEPS PER PMAQ-AB CYCLE

This cooperation expanded the institutional capacity of MS for the implementation of the policy, being reinforced by the association of IEPs as a strategy used to overcome administrative limitations for the decentralization of federal financial resources.

There was a limitation in the capacity of MS to establish a cooperation term with all universities, but they managed to associate themselves by building an interesting expertise, which involved IEPs throughout the country, since the external evaluation required territorial coverage [...]. Part of the IEPs that received federal resources to conduct the evaluation constituted state coordinations for the execution of activities in a decentralized manner, creating consortia with local IEPs (E-3).

The interviewees argued about the importance of constituting this network of IEPs, emphasizing their objectives and potential.

If the process of formalizing cooperation had taken place through a research public notice for the selection of universities, those that usually managed to win the competition would participate in the PMAQ-AB. However, this associative design allowed to expand the performance of the IEPs (E-3).

The purpose was to mobilize pairs that had an expanded conception of collaborative work and an idea of composition research/teaching/extension inseparable and, more than that, of commitment to the strengthening of SUS (E-4).

There were more than 40 IEPs involved in the project, based on an inclusive process, in which the gathering of these universities in different consortia also results from joint participation in previous projects (E-7).

This represents a milestone of PMAQ-AB, because there has never been this many universities cooperating and evaluating AB in the country [...]. This involvement of IEPs in the various Brazilian states also allows greater integration with the local SUS (E-6).

5. DISCUSSION

Studies reveal the existence of points of convergence between path dependence and institutional changes. Different analyzes show the presence of political and institutional legacy in the policy development process in the Brazilian State (Chagas, 2016; Fernandes & Wilson, 2013; A. C. A. Sousa & Costa, 2013). In these studies, we observed that the political strategies adopted formatted the institutions. In this sense, this article, based on the historical-institutionalist approach, shows that, in the context of a party-political continuity government, the process of institutional change in the Federal Executive in 2011, and the characteristics, and actions of the actors of the government and the MS core are central to explaining the genesis of the PMAQ-AB and, consequently, of government-academia institutional cooperation.

The Dilma government was, from the beginning, marked by a managerialist vision based on a technical rationality (Machado et al., 2017), whose expansion of financial investment in some areas was associated with the ability to produce data and present positive politics results (Gomes & Merhy, 2016; A. N. Sousa, 2018). In this government, several actors with similar political-academic trajectory and sharing certain values, objectives, and ideas occupied strategic positions in the high echelon of the MS, influencing the direction and format of health policy. This situation favored greater openness to the theme of AB and evaluation, as can be seen in the Strategic Planning of the MS (Ministry of Health, 2014), as well as for the approach to the academic community, an understanding also conceived by Ferla (2020), Gomes and Merhy (2016), Pinto et al. (2014), A. N. Sousa (2018).

The analysis of this scenario revealed the existence of links between government actors and researchers and communication channels that facilitate this approximation between politics and academia, according to Pouvourville (1999), Trostle, Bronfman, and Langer (1999). It is considered, therefore, that policies are formulated not only when leaders are in the sphere of government, but also originate in spaces that allow the creation of connections between individuals who end up forming a relational network, disputing ideas and proposals among themselves, and with other groups. It can be said that certain lines of force in the political and social field have connected different actors in recent health policies, favoring the approximation between public leaders and academics (Ferla, 2020).

The connection between these actors can be understood based on certain vectors, which connect with the process of redemocratization of Brazil, the construction of political parties and unions, the health movement, and the student movement (Escorel, 1998; Gomes, Barbosa, & Ferla, 2016). All of this is interconnected to the role played by academics in these movements and in the relationships that encompass universities. These processes allowed the creation of relationships between the actors involved, who began to share, at some point, spaces for professional performance.

It was in this political-institutional context of the Federal Government that the financing of primary care emerged as a central agenda, and the allocation of financial resources was conditioned to objectives and guidelines of health policy. Also in 2011, the MS instituted a quality component in the AB financing block, with the PMAQ-AB (Pinto et al., 2014; A. N. Sousa, 2018), with the objective of expanding the responsiveness of this level of care of the system to the health problems of the country (Cavalcanti et al., 2021). The program inaugurated the institution of formal performance compensation mechanisms in SUS, linked to nationally standardized monitoring and evaluation procedures (Pinto et al., 2014; A. N. Sousa, 2018). At first, the PMAQ-AB was organized into four phases that constituted a programmatic cycle, whose normative revision occurred in 2015 restricted to three: accession and contractualization, certification and re-contractualization (Cavalcanti & Fernandez, 2020).

The decision to carry out an evaluation process of national dimension in SUS made it necessary to mobilize political-institutional efforts for its implementation in the country, given the centrality of the PMAQ-AB - which articulates with structuring initiatives of the National Primary Care Policy (PNAB) - and also due to the transfer of federal resources to the local health authority according to the performance achieved in the evaluation processes (Cavalcanti et al., 2021; Pinto et al., 2014; A. N. Sousa, 2018). But, above all, given that the Federal Executive body, responsible for the implementation of public health policy nationally, does not have the attribution and institutional capacity to operationalize an external evaluation of this scale in the extensive territory of the country, with significant geographical and political diversity (Cavalcanti et al., 2021). The characteristics of the policy and the ministerial team were able to mobilize support in the academic community for the implementation of the PMAQ-AB through cooperation with the IEPs.

This cooperation expanded the institutional capacity of MS to evaluate intergovernmental actions in the SUS, with the creation of an institutional arrangement formed by a set of IEPs, of which a part historically acts politically institutionally for the consolidation of evaluative research in the Brazilian AB, notably supported by the Primary Health Care Research Network of ABRASCO, 2018 (APS Network). Within the scope of the PMAQ-AB, the APS Network acted with organized political support in the articulation with the MS and in the mobilization of dozens of IEPs to operationalize this evaluative research of AB and maintain a historical cooperation, of approximately a decade, before the DAB-MS, as shown by this research and the studies of Cavalcanti et al. (2021), Fausto, Mendonça, and Giovanella (2013), Ferla (2020), Primary Health Care Research Network of ABRASCO (2018), A. N. Sousa (2018), Uchôa et al. (2018).

Therefore, the partnership between the MS and the IEPs for the development of evaluation processes is not a novelty of the PMAQ-AB. The political-institutional context of the PMAQ-AB is dependent on previous policies or choices, particularly from the 1990s, with the emergence of Family Health, when cooperation between government and academia intensified, with a focus on strengthening the institutionalization of monitoring and evaluation in the SUS (Primary Health Care Research Network of ABRASCO, 2018; A. N. Sousa, 2018), and in the following decade, also influenced by force vectors of the second generation of public sector reforms, with a focus on the qualification of AB (Abrucio, 2007). In other words, the government-academia cooperation in the PMAQ-AB results in a historical process whose previous initiatives in the field of public health connected public leaders and academics due to the mutual interest in the consolidation of the SUS, while interests and organizations were constituted and structuring political resources of the academia-SUS partnerships were concentrated, evidencing their path dependency character.

According to Cavalcanti et al. (2021), this formal cooperation between the Federal Government and IEPs was fundamental to ensure the implementation of the program during three cycles. The IEPs mobilized their institutional apparatus to carry out the external evaluation of the PMAQ-AB in thousands of UBS/teams in the country. Their participation aimed to fill technical gaps of various orders in the formulation and operationalization of this evaluation of great magnitude in the SUS and management support. In addition, it conferred a greater degree of qualification, exemption, legitimacy, and political and technical credibility to a process with the characteristics of the PMAQ-AB, due to the social function that is reflected in interests, values and culture, among other particular characteristics that differentiate them institutionally from other organizations (Freire-Maia, 2007).

From the point of view of the legality of the public administration, these elements also reinforce cooperation, especially in view of the need to elaborate criteria for the transfer of financial resources to local health authorities, as well as for the use, by IEPs, in the development of scientific studies associated with the interests of academia (Cavalcanti et al., 2021; Gomes & Merhy, 2016).

Based on the findings of this research and in line with Ferla (2020), it is understood that this cooperation in the PMAQ-AB does not constitute a service provision according to a formal selection process. It is a matter of mobilizing public institutions, mainly through a formal mechanism for sharing public sector budgetary resources, for the development of common actions in the field of research, with scientific and technological support for the improvement of public health policy. Therefore, as the SUS develops, the interactions between science and politics become essential to ensure more judicious decision-making processes in defining and implementing public policies, according to the foundations of the policies informed by evidence. The capacity to generate new scientific and technological knowledge, on the one hand, and the need to achieve more advanced levels of quality of SUS services, on the other, define the frequency and type of cooperation in the context of path dependency.

6. CONCLUSION

This research, based on the NH, evidenced some arguments that were considered for building formal cooperation between government and academia in SUS. The option for cooperation with the IEPs cannot be properly understood without analyzing the political-institutional context of the Federal Government in 2011, also considering the actors institutionally relevant in the elaboration of the policy, their interests, objectives, ideas, and actions.

The origin of this institutional cooperation results from the political process of the genesis of the PMAQ-AB, which was an initiative for the institutionalization of monitoring and evaluation in the AB of SUS, as well as a reference for the federal financing model, which innovated with the establishment of a payment for performance mechanism in Brazilian public health. This cooperation shows political-institutional characteristics of the Federal Government regarding the institutional capacity of government agencies to implement evaluation processes linked to performance payment mechanisms.

The contingencies inherent to the MS provided cooperation with the academia under the argument of implementing government policy. The external evaluation of the teams that joined the PMAQ-AB then became the object of government-academia institutional collaboration. This process is the result of intergovernmental mobilization and approximation of the MS with the IEPs to meet the operational needs of PMAQ-AB, which certainly expanded the institutional capacity based on the consortium of dozens of IEPs in the country to carry out the evaluative research of AB nationally. Thus, this government-academia approach is related to the institutional nature and the possibility regarding their missions, in the perspective of the implementation of PMAQ-AB in SUS.

In this study, more forceful criticisms about the effectiveness of cooperation with the IEPs were not addressed. This limitation may be related to the choice of interviewees. It is suggested, therefore, that future research complement it, being able to explore the vision of local health actors, leaders, and team professionals, in addition to investigating aspects related to the interaction between public agents and academics, revealing the interests and arguments that supported this institutional arrangement for approximately a decade, especially from the perspective of tripartite governance of the SUS.

FUNDING

The article results from research carried out with financial support from the National Council for Scientific and Technological Development (CNPq), through the granting of a doctoral scholarship (process No. 141060/2017-4), and research assistance (process No. 400735/2019-9).

• [Translated version] Note: All quotes in English translated by this article’s translator.

REFERÊNCIAS

• Abrucio, F. L. (2007). Trajetória recente da gestão pública brasileira: um balanço crítico e a renovação da agenda de reformas. Revista de Administração Pública, 41(spe), 67-86.
• Bardin, L. (2015). Análise de conteúdo São Paulo, SP: Edições 70.
• Bernardi, B. B. (2012). O conceito de dependência da trajetória (path dependence): definições e controvérsias teóricas. Perspectivas: Revista de Ciências Sociais, 41, 137-167.
• Bertusso, F. R., & Rizzotto, M. F. (2018, junho). PMAQ na visão de trabalhadores que participaram do programa em Região de Saúde do Paraná. Saúde em Debate, 42(117), 408-419.
• Cavalcanti, P., & Fernandez, M. (2020). Programa de Melhoria do Acesso e da Qualidade da Atenção Básica: uma análise das principais mudanças normativas. Physis: Revista de Saúde Coletiva, 30(3), e300323.
• Cavalcanti, P., Fernandez, M., & Gurgel, G. D. Jr. (2021). Cooperação entre academia e governo para avaliar a APS no SUS. Interface, 25, e210103.
• Chagas, K. (2016). Dependência da trajetória e mudança institucional nos processos de desenvolvimento. Revista Brasileira de Ciência Política, 19, 253-275.
• Escorel, S. (1998). Reviravolta na saúde: origem e articulação do movimento sanitário Rio de Janeiro, RJ: Fiocruz.
• Fausto, M. C., & Fonseca, H. M. (2013). Rotas da atenção básica no Brasil: experiências do trabalho de campo PMAQ-AB Rio de Janeiro, RJ: Saberes.
• Fausto, M. C., Mendonça, M. H., & Giovanella, L. (2013). Experiências de avaliação da Atenção Básica no Brasil: notas para um debate. In M. R. Fausto, H. S. Fonseca, M. C. Fausto, & H. M. Fonseca(Eds.), Rotas da atenção básica no Brasil: experiências do trabalho de campo PMAQ-AB (pp. 291-331). Rio de Janeiro, RJ: Saberes.
• Ferla, A. A. (2020). O desenvolvimento do trabalho na atenção básica como política e como efeito pedagógico inusitado: movimentos do PMAQ-AB. In M. Akerman, P. R. Sanine, M. C. G. C. Bava, F. A. Marim, M. Louvison, L. B. Hirooka, C. K. Morais, & M. C. C. Marques (Orgs.), Atenção básica é o caminho! Desmontes, resistências e compromissos (pp. 94-124). São Paulo, SP: Hucitec.
• Fernandes, A. S. A., & Wilson, R. H. (2013). Mudança institucional e gestão metropolitana no Brasil: o municipalismo autárquico e as finanças municipais metropolitanas. Revista de Administração Pública, 47(3), 777-800.
• Freire-Maia, N. (2007). A ciência por dentro (7a ed.). Petrópolis, RJ: Vozes.
• Gomes, L. B., Barbosa, M. G. & Ferla, A. A. (2016). Atenção básica: olhares a partir do PMAQ-AB Porto Alegre, RS: Rede Unida.
• Gomes, L. B., & Merhy, E. E. (2016). Uma análise política do Programa Nacional de Melhoria do Acesso e da Qualidade da Atenção Básica. In L. B. Gomes, M. G. Barbosa, A. A. Ferla (Eds.), Atenção básica: olhares a partir do PMAQ-AB (pp. 49-73). Porto Alegre, RS: Rede Unida.
• Hall, P. A., & Taylor, R. (2003). As três versões do neoinstitucionalismo. Lua Nova, 58, 194-224.
• Immergut, E. M. (1998). The theoretical core of the new institutionalism. Politics and Society, 26(1), 5-34.
• Lima, L. D., Machado, C. V., & Gerassi, C. D. (2015). O neoinstitucionalismo e a análise de políticas de saúde: contribuições para uma reflexão crítica. In R. A. Mattos, & T. W. Baptista(Eds.), Caminhos para análise das políticas de saúde Porto Alegre, RS: Rede Unida.
• Machado, C. V., Lima, L. D., & Baptista, T. W. (2017). Políticas de saúde no Brasil em tempos contraditórios: caminhos e tropeços na construção de um sistema universal. Cad. Saúde Pública, 33(Suppl. 2), e00129616.
• Mahoney, J. (2000). Path dependence in historical sociology. Theory and Society, 29(4), 507-548.
• Minayo, M. (2014). O desafio do conhecimento: pesquisa qualitativa em saúde (14a ed.). São Paulo, SP: Hucitec.
• Ministério da Saúde. (2011a). Discurso de posse Presidente (2011-2016: Dilma Vana Rousseff) Brasília, DF: Presidência da República.
• Ministério da Saúde. (2011b). Discurso de posse Ministro (2011-2014: Alexandre Rocha Santos Padilha) Brasília, DF: Presidência da República.
• Ministério da Saúde. (2014). Planejamento estratégico do Ministério da Saúde: 2011-2015: resultados e perspectivas(4a ed.). Brasília, DF: Ministério da Saúde.
• Ministério da Saúde. (2015). Portaria nº 1.645, de 2 de outubro de 2015 Dispõe sobre o Programa Nacional de Melhoria do Acesso e da Qualidade da Atenção Básica. Brasília, DF: Autor. Recuperado dehttp://bvsms.saude.gov.br/bvs/saudelegis/gm/2015/prt1645_01_10_2015.html
  » http://bvsms.saude.gov.br/bvs/saudelegis/gm/2015/prt1645_01_10_2015.html
• Ministério da Saúde. (2017a). Manual para o trabalho de campo PMAQ - 3º Ciclo (Avaliação Externa) Brasília, DF: Autor.
• Ministério da Saúde. (2017b). PMAQ-AB: manual instrutivo para as equipes de atenção básica e NASF Brasília, DF: Autor.
• Ministério da Saúde. (2018). Nota metodológica da certificação das equipes de atenção básica participantes do PMAQ Brasília, DF: Autor.
• North, D. (2018). Instituições, mudança institucional e desempenho econômico São Paulo, SP: Três Estrelas.
• Ouverney, A. M., & Fleury, S. (2017). Polarização federativa do SUS nos anos 90: uma interpretação histórico-institucionalista. Revista de Administração Pública, 51(6), 1085-1103.
• Pereira, A. M. (2014). Análise de políticas públicas e neoinstitucionalismo histórico: ensaio exploratório sobre o campo e algumas reflexões. In F. L. Guizardi, G. Nespoli, M. L. S. Cunha, F. R. S Machado, M. C. R. Lopes (Eds.), Políticas de participação e saúde(pp. 143-164). Rio de Janeiro, RJ: EPSJV.
• Pierson, P. (2004). Politics in time: history, institutions, and social analysis Princeton, NJ: Princeton University Press.
• Pierson, P. (2000). Increasing returns, path dependence, and the study of Politics. The American Political Science Review, 94(2), 251-267.
• Pinto, H. A., Sousa, A. N., & Ferla, A. A. (2014). O Programa Nacional de Melhoria do Acesso e da Qualidade da Atenção Básica: várias faces de uma política inovadora. Saúde em Debate, 38(spe), 358-372.
• Pouvourville, G. (1999). Public health research: between science and action? Cadernos de Saúde Pública, 15(4), 889-894.
• Rede de Pesquisa em Atenção Primaria à Saúde da Abrasco. (2018). Contribuição para uma agenda política estratégica para a Atenção Primária à Saúde no SUS. Saúde em Debate, 42(spe1), 406-430.
• Rodrigues, V., Santos, C. R., & Pereira, M. U. (2014). A experiência de planejar e operacionalizar o PMAQ-AB no estado do Acre. Saúde em Debate, 38(spe), 173-181.
• Sousa, A. C. A., & Costa, N. R. (2013). Incerteza e dissenso: os limites institucionais da política de saneamento brasileira. Revista de Administração Pública, 47(3), 587-599.
• Sousa, A. N. (2018). Monitoramento e avaliação na atenção básica no Brasil: a experiência recente e desafios para a sua consolidação. Saúde em Debate, 42(spe), 289-301.
• Souza, C. (2017). Modernização do Estado e construção de capacidade burocrática para a implementação de políticas federalizadas. Revista de Administração Pública, 51(1), 27-45.
• Uchôa, S. A., Martiniano, C. S., Queiroz, A R., Bay, O. D. Jr., Nascimento, W. G., Diniz, Í. A., ... Hartz, Z. M. A. (2018). Inovação e utilidade: avaliação externa do PMAQ-AB. Saúde em Debate, 42(esp), 100-113.
• Yin, P. K. (2015). Estudo de caso: planejamento e métodos (5a. ed.). Porto Alegre, RS: Bookman.

Publication Dates

• Publication in this collection
  18 May 2022
• Date of issue
  Mar-Apr 2022

History

• Received
  18 Nov 2021
• Accepted
  23 Mar 2022