Abstract

Regional Health Planning is a health services' hierarchization strategy that allows actions and services decentralization. Nonetheless, some challenges to implementing regional health planning are identified, such as difficulties in coordinating actions and services in different geographic locations, with different managements to meet population health needs with adequate scale, quality, and cost. In this context, intercity health consortia emerge as an organizational solution that allows better coordination and integration between federative entities, and their main benefits are scale gain in public services delivery; rationalization of processes and expenses; and realization of joint projects that would be impossible to be implemented if managed and funded in isolation. This paper aims to understand how health consortia reach better performance in the procurement and hiring of services by cooperative action through a narrative literature review. The results are organized into three parts: i) definition and concepts of public consortium; ii) definition and concepts of intercity health consortium (CIS); iii) health consortium case studies in Brazil.

Key words
Health consortia; Regional health planning; Decentralization; Local health systems

Introduction

Health systems can be defined based on their laws and regulations, the form of financing, logics of administration, and the scope of services to serve a given population¹1 Santos I. O Mix Público-Privado no Sistema de Saúde Brasileiro: elementos para a regulação da cobertura duplicada [tese]. Rio de Janeiro: Escola Nacional de Saúde Pública; 2009.. Biassoto Júnior et al.²2 Biasoto Júnior G, Silva P, Dain S. Regulação do setor saúde nas Américas: as relações entre o público e o privado numa abordagem sistêmica. Brasília: OPAS; 2006. states that there are broad discussions about the construction of universal, equitable, and comprehensive health systems that guarantee people's access to quality and resolute services. In Brazil, health has remained as the first and foremost problem faced by the population in daily life in recent years, and public underfunding of the health sector is one of the impeding factors for compliance with the constitutional precepts of universal access and comprehensive care³3 Conselho Nacional de Secretários de Saúde (CONASS). Para entender a gestão do SUS: a gestão do SUS. Brasília: CONASS; 2015..

Health decentralization and municipalization in Brazil were discussed at the Ninth National Health Conference. Buss⁴4 Buss P. A IX Conferência Nacional de Saúde. Cad Saude Publica 1991; 7(3):297-300. states that, as the minimum cell of Brazilian political-administrative structure, the municipality can theoretically organize a health system more suited to the needs of its population, as it is closer to the concrete space where people live and more sensitive to their pressures and demands. However, the author points out the need for institutional municipal development to empower them to formulate and implement these social policies.

Souto Júnior⁵5 Souto Júnior JV. O papel da CIB/MG no processo de regionalização do SUS em Minas Gerais [dissertação]. Rio de Janeiro: Escola Nacional de Saúde Pública; 2010. argues that regionalization presupposes a population-based and territory-based organization of the SUS that seeks a distribution of services and promotes access equity, quality, streamlined resources, and rational spending. Kehrig et al.⁶6 Kehrig RT, Souza ES, Scatena JHG. Institucionalidade e governança da regionalização da saúde: o caso da região Sul Mato-Grossense à luz das atas do colegiado de gestão. Saúde Debate 2015; 39(107):948-961. reinforce that the establishment of regionalized health care networks is agreed among the managers involved to define shared or not shared responsibilities, for example, through the Regional Interagency Commissions (CIR).

However, despite the benefits, there are still challenges to implement regionalization, such as the difficulties to integrate and coordinate actions and services in different geographical spaces, with different managements, to meet the health needs and demands of the population in the correct scale, quality, and costs⁷7 Conselho Nacional de Secretários de Saúde (CONASS). Para entender a gestão do SUS. Brasília: CONASS; 2011.. Also, this guideline implies service delivery fragmentation and lower bargaining power in the procurement of materials and services.

In the context of budgetary constraints in public management and the need to increase the efficiency of the use of public resources, associated with the complex SUS management in a federalist system and with explicit decentralization and regionalization policies, public consortia emerge as an organizational solution to meet coordination and integration needs among federative entities. Consortia's benefits are the gain in scale in the provision of public services, rational processes and expenses, the accomplishment of joint projects that are impracticable in isolation, and the political strengthening of regions that until then had negligible state representation⁸8 Baldissera DS. Consórcios Públicos Intermunicipais no Brasil: Panorama após os 10 anos da Lei 11.107/2005 [dissertação]. Rio de Janeiro: FGV; 2015..

Concerning material procurement and service contracting processes, consortia have shown better performance compared to individual procurement in each of the federative entities. Studying the Itajaí Valley (Santa Catarina) Intercity Health Consortium, Amaral and Blatt⁹9 Amaral SMS, Blatt CR. Consórcio intermunicipal para a aquisição de medicamentos: impacto no desabastecimento e no custo. Rev Saude Publica 2011; 45(4):1-3. observed an approximate decline of 48.0% in the number of items that were missing in at least one day, between 2007 and 2009. Ferraes and Cordoni Junior¹⁰10 Ferraes AMB, Cordoni Júnior L. Consórcio de medicamentos no Paraná: análise de cobertura e custos. Revista de Administração Pública 2007; 41(3):475-486. focused their analysis on the Paraná Saúde Consortium and found that, in 2000, procurement through this entity achieved a 29.7% lower cost than the prices disclosed in the Ministry of Health Price Bank.

Given the above points, this paper aims to investigate how intercity health consortia can achieve better performance regarding the procurement and contract of services processes through a narrative bibliographic review.

Therefore, this publication is shown in three parts: i) the bibliographic search method; ii) exposure of the main contents extracted by reading the papers, dissertations, theses, and other documents collected; iii) conclusions and final comments.

Methods

Gil¹¹11 Gil A. Como elaborar projetos de pesquisa. São Paulo: Atlas; 2008. states that bibliographic research is understood as a process that involves the following steps: choosing the theme; preliminary bibliographic survey; formulation of the problem; drafting of the subject's provisional plan; source search; reading of the material; annotations; logical organization of the subject; and text drafting.

Reviews can be systematic, narrative, and integrative. This work is characterized as a narrative review. Rother¹²12 Rother ET. Revisão sistemática X revisão narrativa. Acta Paulista de Enfermagem 2007; 20(2):vii-viii. affirms that narrative review papers are broad publications that describe and discuss the development or state of the art of a given subject, from a theoretical or contextual viewpoint. The author says this type of research consists of the analysis of the literature published in books, magazine papers, and the interpretation and personal critical review of the author. The literature review method in this research is summarized in Figure 1.

This research used specialized Brazilian and international health databases, as well as journal databases gathering various subjects besides public health.

The chosen specialized Brazilian health database was the Virtual Health Library (BVS), and the international database was PubMed. As for non-specialized databases, we chose to use the ISI Web of Knowledge and SCOPUS, as they contain the journals with the most considerable bibliometric impact in the world.

In the search conducted in the BVS database, we aimed to search for papers, master's dissertations, doctoral theses, and technical reports that were not indexed by ISI, SCOPUS, or PubMed, and that had specific “views” about the Brazilian reality. On this basis, we adopted keywords “consortium” and “health,” and the search, without restrictions as to the year of publication, returned 173 publications. Given that this is a highly active topic, we decided to restrict the selection to publications after 2000, and 113 papers remained. After reading the abstracts of these works, to recognize the specific object of those publications and verify their suitability for the specific purpose of this research, concerning the performance in the procurement of materials and contracting services by the consortia, we found that only twenty publications were in line with this research.

In the SCOPUS database, a first attempt was made with the keywords “health” and “consortium,” without restriction as to the date of publication, which returned 7,005 papers addressing the topic returned. This result dropped to 5,918 publications when applying a new filter for post-2000 research. With a still high number, we decided to add one more keyword, namely, “purchasing,” because this study focuses on the understanding of how consortia can be an instrument to achieve better performance in procurement processes, which shortlisted the results to 74 papers. After reading the abstracts, we identified that only ten papers had a direct relationship with the object of this research.

The same search engine was applied in the ISI – Web of Knowledge database. Keywords “health” and “consortium,” without restriction on the period of publication, returned 3,688 papers. Restricting the period to the 2000-2017 period, it returned 3,292 papers, which, by adding the keyword “purchasing,” dropped to 19 works. When reading the abstracts, four publications were within the scope of this research, but three of them coincided with publications found in the SCOPUS database search.

When submitting the same keywords in the PubMed database, we observed that the journals contained therein were indexed by any of the three previously consulted databases, returning publications that had already been analyzed in previous searches.

Results

The results of the literature review were divided into three blocks. The first block shows definitions, advantages, and disadvantages of public consortia in Brazil, without a specific focus on health, but for understanding this instrument's advantages for cooperative projects and processes among federative entities. The second block focuses specifically on the Intercity Health Consortia (CIS), highlighting their definitions, history, and primary management challenges. The last block shows some cases of CIS in Brazil, with a look at its main results, especially for the procurement of goods and for the cooperative contracting of services, besides the difficulties for its implementation, maintenance, and management.

Chart 1 shows the publications used in this narrative review by displaying titles, authors, year of publication, the vehicle of publication, and main subjects covered.

Public consortia: definitions, advantages, and disadvantages

The Observatory of Public Consortia and Federalism⁴⁰40 Strelec TC. Desafios da Adaptação à Lei de Consórcios Públicos: experiências concretas no Estado de São Paulo. In: Anais do VI Congresso de Gestão Pública - CONSAD; 2011; Brasília. p. 2-20. recognizes that the 1988 Constitution enshrined the Brazilian federative system based on an agreement establishing the autonomy of the territorial spheres of power. While the federalist model provides gains, the Brazilian federation is characterized by the strong asymmetry between governments, which brings the need to plan policies to correct or minimize inequalities between states and municipalities³³33 Chaebo G, Guerra M, Pinto D, Alfinito S. Constituição de Consórcios Intermunicipais de Saúde: Uma Aplicação da Técnica de Agrupamento por Clusters. Latin American Journal of Business Management. 2015; 6(2):149-169..

Baldissera⁸8 Baldissera DS. Consórcios Públicos Intermunicipais no Brasil: Panorama após os 10 anos da Lei 11.107/2005 [dissertação]. Rio de Janeiro: FGV; 2015. states that the decentralization model was not accompanied by instruments for planning and coordinating government actions, and, in this context, intercity consortia emerged as a coordinating mechanism located in spheres that transcend the territorial boundaries of municipalities, and at the same time, do not reach the limits of states. Public consortia can be understood as an organizational solution to meet the needs of coordination and integration among federative entities, intended to operate delegated competences, as an expression of the exercise of autonomy of consortium entities⁴¹41 Cruz MCMT, Araújo FF. Consórcios intermunicipais paulistas rumo aos consórcios públicos - reflexões. In: Anais do VI Congresso de Gestão Pública - CONSAD; 2011; Brasília. p. 2-20.

It is an instrument of technical and financial cooperation between municipalities, states, and the Federal Government, which can serve to articulate assets, enable cooperation in regional projects, works, and other actions aimed at promoting the development of a given region⁴²42 Muller EV, Grecco M. Avaliação da satisfação dos usuários com os serviços do consórcio intermunicipal de saúde do noroeste do Paraná. Cien Saude Colet 2010; 15(3):925-930..

While Law 11.107/2005⁴³43 Oliveira VE. Municípios cooperando com municípios: relações federativas e consórcios intermunicipais de saúde no Estado de São Paulo. São Paulo em Perspectiva 2008; 2(1):107-122., or Law of Consortia, institutionalized the figure of public consortia in Brazil only in 2005, some consortium mechanisms existed before then³⁹39 Martinelli N. A regionalização da saúde no Estado do Mato Grosso: o processo de implementação e a relação público-privada na região de saúde do Médio Norte mato-grossense [tese]. São Paulo: USP; 2014.. In these structures, the groups of federated entities, mostly municipalities, were associated horizontally and cooperatively and decided to collaborate, not for profit, to solve common issues in a particular area, without legal personality, with only one protocol of intent.

Taking into account the principle of economy, even with the ability to provide the service in isolation, it may be advantageous to seek partnership with other municipalities, spending fewer resources and achieving the same results. One can also increase the quality of the services provided by maintaining the expenses that would be incurred in isolation⁸8 Baldissera DS. Consórcios Públicos Intermunicipais no Brasil: Panorama após os 10 anos da Lei 11.107/2005 [dissertação]. Rio de Janeiro: FGV; 2015..

Linhares et al.⁴⁴44 Botti CS, Artmann E, Spinelli MAS, Scatena JHG. Regionalização dos Serviços de Saúde em Mato Grosso: um estudo de caso da implantação do Consórcio Intermunicipal de Saúde da Região do Teles Pires, no período de 2000 a 2008. Epidemiol. Serv. Saúde 2013; 22(3):491-500. noted that consortia prove to be very valuable instruments in the performance of policies aimed at solving problems that occur in multi-municipal territorialities, such as health, environment, and infrastructure.

The sustainability of consortia requires a consistent political agreement between federative actors, aiming at long-term goals to the detriment of immediacy, and one that can address diversity to the detriment of unilateral decision-making⁴¹41 Cruz MCMT, Araújo FF. Consórcios intermunicipais paulistas rumo aos consórcios públicos - reflexões. In: Anais do VI Congresso de Gestão Pública - CONSAD; 2011; Brasília. p. 2-20.

Moreover, the difficulties faced by federative entities are transported to consortia, such as low qualification of civil servants, conflicting agendas between areas, planning gaps, bureaucratic barriers, and finite and misapplied resources.

Despite the flexibility generated by consortia, many face obstacles to their operation because of legal fragility, difficulty in relationship with other federated entities, lack of commitment and responsibility to pay municipal contributions, political use of a consortium, and fiscal irresponsibility³⁵35 Teixeira L, Mac Dowell MC, Bugarin M. Consórcios Intermunicipais de Saúde: Uma Análise à Luz da Teoria dos Jogos. Rev. Bras. Econ. 2003; 57(1):253-281..

The Intercity Health Consortia (CIS)

The decentralization of the health policy, provided for in the 1988 Constitution⁴⁵45 Brasil. Constituição da República Federativa do Brasil Brasília: Imprensa Nacional; 1988., generated a significant increase in the participation of municipalities in the provision of health services²⁴24 Datta D, Figueira JR, Gourtani AM, Morton A. Optimal administrative geographies: An algorithmic approach. Socio-Economic Planning Sciences 2013; 47(3):247-257.. However, the transfer of the Federal Government's responsibilities to states and municipalities has faced obstacles related to organizational and financial deficiencies, as well as inefficiencies due to problems of scale and scope caused by fragmented services³¹31 Neves LA, Ribeiro JM. Consórcios de saúde: estudo de caso exitoso. Cad Saude Publica 2006; 22(10):2207-2217.. The author mentions a loss of production scale, resulting from the increased number of establishments and equipment, which led to inefficient health systems and reduced quality of services provided to the population.

A large number of small municipalities with limited or no availability of medium and high complexity services have shown that decentralization must be accompanied by intergovernmental coordination and cooperation strategies⁶6 Kehrig RT, Souza ES, Scatena JHG. Institucionalidade e governança da regionalização da saúde: o caso da região Sul Mato-Grossense à luz das atas do colegiado de gestão. Saúde Debate 2015; 39(107):948-961..

Municipalities must incorporate innovative ways of managing and organizing service networks through collective institutional construction⁶6 Kehrig RT, Souza ES, Scatena JHG. Institucionalidade e governança da regionalização da saúde: o caso da região Sul Mato-Grossense à luz das atas do colegiado de gestão. Saúde Debate 2015; 39(107):948-961. to implement the health regionalization policy. Thus, Neves and Ribeiro²⁴24 Datta D, Figueira JR, Gourtani AM, Morton A. Optimal administrative geographies: An algorithmic approach. Socio-Economic Planning Sciences 2013; 47(3):247-257. state that intercity health consortia (CIS) are organizational arrangements that have been the frequent object of evaluation of results, impacts and implementation mechanisms in the academic community, as they favor the construction of agreed regional systems and, thus, facilitate the implementation of decentralization strategies for regionalization and hierarchization of the SUS in the provision of services.

CIS are shown as public sector innovations for better management, to provide specialized services and higher technological density to the population, besides generating environmental and economic gains in the provision of these public services²⁵25 Chakraborty S, Bhattachary S, Dobrzykowski DD. Impact of Supply Chain Collaboration on Value Co-creation and Firm Performance: A Healthcare Service Sector Perspective. Procedia Economics and Finance 2014; 11(2014):676-694.. Health consortia aim to solve management and service delivery issues in a specific region through concerted efforts and the articulation of physical, financial, and technological resources in search of solutions to shared problems²⁷27 Reid PP, Compton W, Grossman J, Fanjiang G. Building a Better Delivery System: A New Engineering/Health Care Partnership. Washington: The National Academies Press; 2005.^,2929 Pepino A, Rovani M, Torri A, Sansone M. Supply Chain for Regional Centralized Purchasing: An Application Model. Intelligent Information Management 2012; 4(5A):269-276.. This allows the financial sustainability of investments and contributes to streamlining the care network.

Teixeira et al.²⁸28 Hinrichs S, Jahagirdar D, Miani C, Guerin B, Nolte E. Learning for the NHS on procurement and supply chain management: a rapid evidence assessment. Health Services and Delivery Research 2014; 2(55):1-158. define intercity health consortia as an autonomous initiative of municipalities located in contiguous geographical areas, which associate themselves to jointly manage and provide specialized and diagnostic support services with higher technological density for the population of the participating municipalities. Muller and Greco³⁶36 Botti CS. Avaliação do processo de implementação do Consórcio Intermunicipal de Saúde da região do Teles Pires [dissertação]. Rio de Janeiro: Escola Nacional de Saúde Pública; 2010. highlight consortia as an instrument to solve local challenges, such as expanding and ordering services, contracting services, making remuneration of professionals with incentive payments more flexible, and streamlining the available regional resources, to improve access and quality of services. Consortia agree on rules for financing services and client access based on resources of associated municipalities⁵5 Souto Júnior JV. O papel da CIB/MG no processo de regionalização do SUS em Minas Gerais [dissertação]. Rio de Janeiro: Escola Nacional de Saúde Pública; 2010..

Morais and Chaves²⁵25 Chakraborty S, Bhattachary S, Dobrzykowski DD. Impact of Supply Chain Collaboration on Value Co-creation and Firm Performance: A Healthcare Service Sector Perspective. Procedia Economics and Finance 2014; 11(2014):676-694. realize that most Brazilian municipalities, especially those far from large centers or with low population indices, have a hard time implementing the SUS due to the difficulty of allocating qualified human resources, access to the use of technologies and lack of adequate physical structures. Deriving from this, when analyzing the consortia of the State of Minas Gerais, Rocha and Faria²⁷27 Reid PP, Compton W, Grossman J, Fanjiang G. Building a Better Delivery System: A New Engineering/Health Care Partnership. Washington: The National Academies Press; 2005. found that the municipalities acting jointly can arrive at positive results such as the capacity for achievement, increased service to citizens, greater efficiency in the use of public resources and realization of actions that would be inaccessible to a single municipality.

Thus, they can address individual needs, such as scarce financial, technological, and human resources needed to implement public policies. Thus, Neves and Ribeiro²⁴24 Datta D, Figueira JR, Gourtani AM, Morton A. Optimal administrative geographies: An algorithmic approach. Socio-Economic Planning Sciences 2013; 47(3):247-257. state that the CIS is an alternative organization that can overcome the individual shortcomings of each municipality in health care, especially in specialized medical consultations and medium and high complexity exams, as well as reducing the competitive aspects of Brazilian federalism.

When studying the Cerrado Araguaia Tocantins Intercity Health Consortium, Morais and Chaves²⁵25 Chakraborty S, Bhattachary S, Dobrzykowski DD. Impact of Supply Chain Collaboration on Value Co-creation and Firm Performance: A Healthcare Service Sector Perspective. Procedia Economics and Finance 2014; 11(2014):676-694. realized that intercity consortia hold a strategic position in the hierarchical organizational structure of the municipalities, as they allow the development of intersectoral strategies and practices, and have the necessary autonomy to build partnerships and carry out planning beyond the political and administrative boundaries of the municipalities.

Health consortia enable greater integration of regional health care networks, increasing the supply of beds and access to medium and high complexity networks, as well as strengthening the regional regulatory system⁴⁶46 Batista S. O papel dos prefeitos e das prefeitas na criação e na gestão dos consórcios públicos. Brasília: Caixa Econômica Federal; 2011.. The author also points out that this type of model enables strategic regional planning through the joint mapping of demands, setting priorities, and offering technical assistance aiming at the elaboration of integrated projects. It also allows the referral of joint requests for resources, besides the management of shared contracts and agreements. Rocha and Faria²⁷27 Reid PP, Compton W, Grossman J, Fanjiang G. Building a Better Delivery System: A New Engineering/Health Care Partnership. Washington: The National Academies Press; 2005. point out that, in the case of consortia of the State of Minas Gerais, the regional provision of services avoids the municipality's overload in the construction of new outpatient and hospital services, recruitment of specialized human resources and the procurement of high-cost equipment, enabling better use of the available network.

Another advantage of municipalities adhering to a CIS is the structuring of a network as per the installed capacity of the various actors, thus reducing idle capacity and optimizing the service and referral of patients between municipalities²⁴24 Datta D, Figueira JR, Gourtani AM, Morton A. Optimal administrative geographies: An algorithmic approach. Socio-Economic Planning Sciences 2013; 47(3):247-257.. Also, as they are legal entities governed by private law, they can have greater administrative flexibility, thus allowing the recruitment of people as per the market's logic, paying competitive salaries, as well as offering productivity bonuses, which would tend to improve the performance of professionals and raise the quality of services provided²⁵25 Chakraborty S, Bhattachary S, Dobrzykowski DD. Impact of Supply Chain Collaboration on Value Co-creation and Firm Performance: A Healthcare Service Sector Perspective. Procedia Economics and Finance 2014; 11(2014):676-694..

The consortia reside in a logic of cooperative federalism, in which it is possible to streamline and integrate public actions and foster the adoption of redistributive policies²⁷27 Reid PP, Compton W, Grossman J, Fanjiang G. Building a Better Delivery System: A New Engineering/Health Care Partnership. Washington: The National Academies Press; 2005.. However, the authors point out potential adverse results, such as the subordination of the weaker to the stronger, no clear definition of the distribution of responsibilities, and, thus, lack of accountability of the system.

Regarding the emergence and formation of consortia, Neves and Ribeiro²⁴24 Datta D, Figueira JR, Gourtani AM, Morton A. Optimal administrative geographies: An algorithmic approach. Socio-Economic Planning Sciences 2013; 47(3):247-257. observed two main trends. In the first one, a free association was observed between municipalities as per their political characteristics, and a regionalization following these characteristics. In the second, a governmental induction by state governments, through the creation of mechanisms and incentives to have this association as per their preferences was found. The authors note that consortia are set primarily around small or medium-sized municipalities for the provision of specialized care, and found that 95% of the municipalities that are part of consortia have less than fifty thousand inhabitants, and 60% have less than ten thousand inhabitants. Additionally, Teixeira³¹31 Neves LA, Ribeiro JM. Consórcios de saúde: estudo de caso exitoso. Cad Saude Publica 2006; 22(10):2207-2217. realizes that most of the consortium municipalities (52%) have mean incomes between the fifth and eighth deciles, and this shows that the consortium municipalities are, in general, medium- to high-income municipalities. However, Oliveira³⁷37 Rodrigues A. Cooperação intermunicipal no âmbito do SUS [dissertação]. São Paulo: USP; 2003. states that the consortium mechanism did not spread equally among the Brazilian states and municipalities. Table 1 shows the number of consortia in each of the Brazilian states.

In the case of the consortia of the State of Minas Gerais, Souto Júnior⁵5 Souto Júnior JV. O papel da CIB/MG no processo de regionalização do SUS em Minas Gerais [dissertação]. Rio de Janeiro: Escola Nacional de Saúde Pública; 2010. realized that the autonomy transferred to small municipalities, with less than 30,000 inhabitants, generated a deficit in the provision of health services to the population due to the lack of sufficient and efficient administrative structures, as well as of technicians and human resources in general, and negligible investments. The author points out that municipal autonomy was more sustainable when municipalities decided to consort to buy larger-scale services with a defined scope from their needs through cooperation agreements, ensuring more significant savings.

In the case of the Intercity Health Consortium of the Penápolis Region (CISA), Neves and Ribeiro²⁴24 Datta D, Figueira JR, Gourtani AM, Morton A. Optimal administrative geographies: An algorithmic approach. Socio-Economic Planning Sciences 2013; 47(3):247-257. state that the decision-making structure of the consortia is centered on a Mayors' Council and the consortium is managed by an executive body. Concerning their financing, the authors highlight the contribution of the municipalities to maintain the operation of the consortium and the transfer of resources from the SUS to provide the services themselves. Also, Teixeira et al.²⁸28 Hinrichs S, Jahagirdar D, Miani C, Guerin B, Nolte E. Learning for the NHS on procurement and supply chain management: a rapid evidence assessment. Health Services and Delivery Research 2014; 2(55):1-158. state that funding of these structures derives from three primary sources: municipal quotas (defined by population criteria or use of services), direct SUS resources, and resources originating from the State Health Secretariats.

Galindo et al.³⁹39 Martinelli N. A regionalização da saúde no Estado do Mato Grosso: o processo de implementação e a relação público-privada na região de saúde do Médio Norte mato-grossense [tese]. São Paulo: USP; 2014. highlight the two instruments that formalize the transfer of resources to the consortium: the apportionment agreement and the program agreement. The authors believe that the program agreement helps the Consortium start to perform the public services demanded by society. The apportionment agreement, in turn, defines the economic and financial responsibilities of each consortium member and the way of transferring resources to the public consortium expenses, such as charges, personnel expenses or assets necessary for its operation.

In the case of the consortia of the State of Minas Gerais, Rocha and Faria²⁷27 Reid PP, Compton W, Grossman J, Fanjiang G. Building a Better Delivery System: A New Engineering/Health Care Partnership. Washington: The National Academies Press; 2005. indicate that the relationship of equality between the municipalities was presented as a principle found in the consortium structuring. Thus, they are generally organized from the establishment of a Council of Municipalities (usually consisting of municipal health secretaries), a Fiscal Council (responsible for budgetary and financial management control), and an Executive Secretariat. In the case of the Teles Pires (MT) Micro-region Intercity Health Consortium, Botti²⁹29 Pepino A, Rovani M, Torri A, Sansone M. Supply Chain for Regional Centralized Purchasing: An Application Model. Intelligent Information Management 2012; 4(5A):269-276. notes that, for the development of its actions, the organization uses technical and administrative teams from the municipalities that are part of or contracted by the public selection, under the Consolidated Labor Laws (CLT).

Neves and Ribeiro²⁴24 Datta D, Figueira JR, Gourtani AM, Morton A. Optimal administrative geographies: An algorithmic approach. Socio-Economic Planning Sciences 2013; 47(3):247-257. point out that the sustainability of this model is due to the positive political results generally obtained. The authors studied in depth the case of the Penápolis Health Consortium and realized that one of the reasons for its long-term success was the political stability allowed by the succession of mandates of mayors and councilors, as well as the excellent relationship between the Executive and Legislative powers. Rocha and Faria²⁷27 Reid PP, Compton W, Grossman J, Fanjiang G. Building a Better Delivery System: A New Engineering/Health Care Partnership. Washington: The National Academies Press; 2005. also reinforce that the operation of consortia in the state of Minas Gerais depends on the characteristics of municipal policy and that, in more successful cases, executives seek to base their decisions on technical-instrumental criteria, aiming at preserving the experience against political and electoral interference.

Morais and Chaves²⁵25 Chakraborty S, Bhattachary S, Dobrzykowski DD. Impact of Supply Chain Collaboration on Value Co-creation and Firm Performance: A Healthcare Service Sector Perspective. Procedia Economics and Finance 2014; 11(2014):676-694. point out, specifically in the case of the Cerrado Araguaia Tocantins Intercity Health Consortium, that an obstacle for the consortium is the need to overcome its limits and boundaries for the implementation and monitoring of public health policies, reflecting in the political, economic and care dynamics. Keinert et al.⁴⁸48 Keinert TM, Meneguzzo M, Rosa TC. Inovação e cooperação intergovernamental: microrregionalização, consórcios, parcerias e terceirização no setor saúde. São Paulo: Annablume; 2006. also highlight other challenges to be overcome, such as the sensitization of municipal managers, shortage of human resources, concern about the legal situation, and the understanding of the Court of Accounts directly related to the consortium.

Also, although the benefits of a consortium are clear, some members still behave as free-riders, that is, making use of the public service provided by the consortium, but without participating in its funding, thus weakening the original purpose of the association⁴⁹49 Chaebo G, Guerra M, Pinto DM, Alfinito S. Constituição de Consórcios Intermunicipais de Saúde: Uma Aplicação da Técnica de Agrupamento por Clusters. In: Anais do EnAPG; 2012; Salvador. p. 1-16. It is also noticed that consortia composed of more homogeneous municipalities concerning population, financial resources, and political power seem to be at better odds of succeeding, since, in the case of asymmetries, the most robust municipalities tend to capitalize for themselves the positive effects of cooperation²⁷27 Reid PP, Compton W, Grossman J, Fanjiang G. Building a Better Delivery System: A New Engineering/Health Care Partnership. Washington: The National Academies Press; 2005..

Cases of Intercity Health Consortia

Experiences of high relevance in the consortium are those of the states of Minas Gerais and Paraná, mainly due to the commitment that the governments of these states had with the establishment of consortia⁵5 Souto Júnior JV. O papel da CIB/MG no processo de regionalização do SUS em Minas Gerais [dissertação]. Rio de Janeiro: Escola Nacional de Saúde Pública; 2010.^,2727 Reid PP, Compton W, Grossman J, Fanjiang G. Building a Better Delivery System: A New Engineering/Health Care Partnership. Washington: The National Academies Press; 2005.. In the case of Minas Gerais, it was found that the state government's action was not limited to spreading the concept and providing information for the creation of consortia, but also linking the release of state resources to the consortium of municipalities, thus creating strong incentives for the shaping of these structures in the state.

Galindo et al.³⁹39 Martinelli N. A regionalização da saúde no Estado do Mato Grosso: o processo de implementação e a relação público-privada na região de saúde do Médio Norte mato-grossense [tese]. São Paulo: USP; 2014. highlight the case of Pernambuco and state that, while consortia are an intercity management strategy, the adoption of public consortia as a SUS regionalization strategy resulted from a choice of the state government. The authors realized the recent trend of state participation as consortium financier, through the transfer of funds or the assignment of human resources, materials, equipment, and technical support.

The consortia of the State of Paraná show that their setup was fundamental to improve access to specialized services and expand service coverage⁴⁸48 Keinert TM, Meneguzzo M, Rosa TC. Inovação e cooperação intergovernamental: microrregionalização, consórcios, parcerias e terceirização no setor saúde. São Paulo: Annablume; 2006.. In the case of municipalities that are part of the Health Consortiums of the Association of Municipalities of the Middle Valley of Itajaí, the joint purchase of medicines allowed the reduction of costs, ensuring a greater supply of medicines and lower shortage of the Primary Pharmaceutical Care component, identified through the declining mean number of days for missing medication and the number of missing items⁹9 Amaral SMS, Blatt CR. Consórcio intermunicipal para a aquisição de medicamentos: impacto no desabastecimento e no custo. Rev Saude Publica 2011; 45(4):1-3..

In the case of the Paraná Saúde Consortium, we noted that, by comparing prices between the Ministry of Health's Price Bank and those practiced by the consortium, the prices paid by the Consortium for the purchase of medicines were systematically lower, and the variation observed was 0.7% to 68.0%. The consortium still has an extensive population coverage (88.2% of the state's municipalities and 55.6% of the state's population), thus indicating its potential as an instrument for promoting equity of access to health goods and services¹⁰10 Ferraes AMB, Cordoni Júnior L. Consórcio de medicamentos no Paraná: análise de cobertura e custos. Revista de Administração Pública 2007; 41(3):475-486..

In the state of São Paulo, we highlight the case of the Alto Vale do Ribeira Health Consortium (CISAVAR), where the consortium allowed the expansion of the supply of specialized services, through the better use of existing services (reduced hospital-headquarters idleness), besides reducing the free-rider behavior of neighboring municipalities, which began to contribute financial resources to the hospital to which they were already referring patients³⁷37 Rodrigues A. Cooperação intermunicipal no âmbito do SUS [dissertação]. São Paulo: USP; 2003.. The author also points out an increased bargaining power of the municipalities involved with the state government, bringing resources to the region that would hardly be obtained if they requested them in isolation.

The decentralization of care and management of resources and health actions and services in the state of Mato Grosso began in 1995, through the process of articulation and technical cooperation with the municipalities, where the state government was responsible for this conduct²⁹29 Pepino A, Rovani M, Torri A, Sansone M. Supply Chain for Regional Centralized Purchasing: An Application Model. Intelligent Information Management 2012; 4(5A):269-276.. The author points out that a study conducted by the State Health Secretariat between 1995 and 2000 concerning the performance of health consortia in the region showed an increase in regional outpatient and hospital care resolution, verified by reducing the referral of procedures from the municipalities of the state to the capital Cuiabá and other federated states.

In the case of the Teles Pires (MT) Intercity Health Consortium, we note that the problems not solved by the consortium were related to the referral and counter-referral system and the existence of waiting lists for performing elective procedures and appointments in some specialties. Because of this, we identified the importance of conducting studies to map the real demand, as well as future projections of this demand, for better planning of the consortia regarding their service provision and definition as to their service capacity³⁸38 Teixeira L. Ensaios sobre consórcios intermunicipais de saúde: financiamento, comportamento estratégico, incentivos e economia política. Brasília: Câmara dos Deputados/CODEP; 2007..

As counterexamples, we can cite the states of the North and Northeast regions, which have the lowest resources of specialty services, hospitals, and specialized technical advice, and yet do not widely use the model of health consortia³⁷37 Rodrigues A. Cooperação intermunicipal no âmbito do SUS [dissertação]. São Paulo: USP; 2003.. The author highlights two factors that may inhibit municipal cooperation in these cases. The first would be the territorial extension of the municipalities (substantial, in the case of the northern region), distant from each other, and challenging to access, which hinders people's access to the region's services. The second factor is justified because they are impoverished regions and, therefore, may not have a desirable minimum level of services, since they do not have the requirements concerning equipment and health resources. That is, the consortium would not produce additional gains for the municipalities involved regarding services available to citizens. However, by gathering around a consortium, these municipalities could increase their bargaining power with state and federal governments to raise funds for health.

Teixeira³¹31 Neves LA, Ribeiro JM. Consórcios de saúde: estudo de caso exitoso. Cad Saude Publica 2006; 22(10):2207-2217. believes that states can hold a more proactive position in the process of establishment and maintenance of CIS through two complementary mechanisms. They can foster partnerships by facilitating consortia's adherence to innovative technologies that would otherwise be inaccessible for their high cost. Also, the state can ensure that members of a consortium do not default under a contract between the municipalities and the state, which would ensure the transfer of funds directly to consortia in the event of non-compliance with financial transfer clauses.

Final comments

The forms of intergovernmental relationships and, more specifically, of intercity consortia, is a subject still hardly explored by science regarding public policies³⁷37 Rodrigues A. Cooperação intermunicipal no âmbito do SUS [dissertação]. São Paulo: USP; 2003.. The author believes that, while being a relevant subject, studies on health consortia find it challenging to further explore their findings due to the lack of historical data, especially for small municipalities, which are the most active in the consortium, which hinders the proof of the good results that this type of arrangement can provide.

Additionally, in attempts to rationalize health expenditures, actions focused on reducing expenses related to the supply of materials and services to health systems are more effective than restricting access to the demanders of these services⁵⁰50 Blank R, Burau V. Comparative Health Policy. London: Palgrave Macmillan; 2007.. Also, intercity health consortia have shown advantages regarding the cost of purchasing or contracting services and the reduced shortages of this input and availability of services⁵5 Souto Júnior JV. O papel da CIB/MG no processo de regionalização do SUS em Minas Gerais [dissertação]. Rio de Janeiro: Escola Nacional de Saúde Pública; 2010.^,99 Amaral SMS, Blatt CR. Consórcio intermunicipal para a aquisição de medicamentos: impacto no desabastecimento e no custo. Rev Saude Publica 2011; 45(4):1-3.^,1010 Ferraes AMB, Cordoni Júnior L. Consórcio de medicamentos no Paraná: análise de cobertura e custos. Revista de Administração Pública 2007; 41(3):475-486.^,2727 Reid PP, Compton W, Grossman J, Fanjiang G. Building a Better Delivery System: A New Engineering/Health Care Partnership. Washington: The National Academies Press; 2005.^,4848 Keinert TM, Meneguzzo M, Rosa TC. Inovação e cooperação intergovernamental: microrregionalização, consórcios, parcerias e terceirização no setor saúde. São Paulo: Annablume; 2006.. Thus, actions focused on structuring the relationship between Health Systems and material suppliers and service providers are justified given their potential for improving the efficiency of health services.

Again, exploring the argument of the importance of rationalizing health spending, an indicator widely used by nations is the assessment of the percentage of GDP that is intended for health actions. According to the Global Health Observatory⁵¹51 Global Health Observatory. Databases. [Online]; 2016 [acessado 2016 Out 15]. Disponível em: http://www.who.int/gho/en/.
http://www.who.int/gho/en/... , a World Health Organization institute for monitoring and comparing health indicators across countries, in 2013, Brazil allocated 9.7% of its GDP to health and 6.9% of total government spending.

While the principles of integrality and universality are found in their health care system, we can infer that these objectives are still far from being achieved since government spending represents only 48.2% of total health spending in Brazil, showing that a large proportion of this expenditure is made directly, privately, by households. These data prove, quantitatively, that the Brazilian Health System must be enhanced to achieve its goal of integrality and universality, and this involves improving the purchase of materials and contracting services mechanisms.

From the academic-scientific standpoint, the literature review showed that a large number of studies discuss the historical and legal context of the implementation of consortia in Brazil. Also, some studies focus on understanding the setup or performance of a single intercity consortium (single case study), but few are intended to make a comparison between two or more consortia in the same region. Other studies address consortium performance evaluation, but the issues related to consortium governance are mentioned only as one of the factors that can affect this performance, without detailing these structures and mechanisms.

From the public health's perspective, this research showed that there are definite gains from the adoption of intercity health consortia, especially for small and medium-sized municipalities, and that state governments can be potent inducers of this strategy. However, a challenge for the effective implementation of consortia lies in the governance of these organizations, given the variety of actors involved in this decision-making process.

However, in the researched universe, we can identify a gap of works and publications that try to understand, in detail and in-depth, the structures and governance mechanisms of the consortia. When it comes to organizational structures where decision-making involves several mayors and health secretaries, with possible distinct political orientations and priorities that are not necessarily convergent, studies on the governance of these organizations are a challenge for the advancement of academic studies on the subject.

References

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