Abstract

Introduction

The Brazilian public sector reform process, from the year 2000 and afterwards, experimented a second generation of institutional changes that influenced the adoption of new government programs in the health field, attempting to improve the provision of services to citizens¹1 Gurgel Junior GD. Health sector reform and social determinants of health: building up theoretical and methodological interconnections to approach complex global challenges. Rev Bras Epidemiol. 2014; 17 Suppl 2: 5367. Doi: http://dx.doi.org/10.1590/1809-4503201400060005.
https://doi.org/10.1590/1809-45032014000... . The efforts in the context of the New Public Administration led to an increase in cooperation processes between academia and government agencies in the Brazilian National Health System (SUS). This phenomenon is relatively recent in Latin America and has been the subject of scientific research in recent years²2 Pellegrini Filho A. Pesquisa em saúde, política de saúde e equidade na América Latina. Cienc Saude Colet. 2004; 9(2):339-350., aiming to get a better understanding of the nature and scope of these approximation initiatives.

The Brazilian Ministry of Health (MoH) during the process of reviewing the Basic Care policy in 2011 (PHC), launched the Primary Care Access and Quality Improvement Program (PMAQ-AB). This Program had the aim of implementing changes to improve management capacity and the quality of primary health care offered to the population³3 Cavalcanti P, Fernandez M. Programa de melhoria do acesso e da qualidade da atenção básica: uma análise das principais mudanças normativas. Physis. 2020; 30(3):e300323.. In order to achieve this end, several evaluation strategies and performance-based compensation mechanisms were established, to expand the PHC response capacity to the country’s health problems⁴4 Rede de Pesquisa em Atenção Primaria à Saúde da ABRASCO. Contribuição para uma agenda política estratégica para a Atenção Primária à Saúde no SUS. Saude Debate. 2018; 2 Spe 1:406-430..

The program was implemented across three cycles: the first, from 2011 to 2013; the second, from 2013 to 2015; and the third, from 2015 to 2019. At the beginning, the program was organized in four phases, constituting a programmatic cycle. There was a normative revision in the third cycle that restricted the phases to three: adhesion and contractualization, certification, and re=contractualization. The external evaluation, a component of the certification, consisted in verifying a set of predefined standards based on the application of instruments regarding the infrastructure and environmental conditions, as well as the functioning of the health units, work process, service supply and integration with the health care network and user satisfaction³3 Cavalcanti P, Fernandez M. Programa de melhoria do acesso e da qualidade da atenção básica: uma análise das principais mudanças normativas. Physis. 2020; 30(3):e300323..

In order to carry out this evaluation process, between 2011 and 2019, the MoH signed institutional cooperation agreements with Brazilian teaching and research institutions (IEP). Some of these IEPs have been working in partnership with the MoH to carry out PHC evaluative research since the previous decade⁴4 Rede de Pesquisa em Atenção Primaria à Saúde da ABRASCO. Contribuição para uma agenda política estratégica para a Atenção Primária à Saúde no SUS. Saude Debate. 2018; 2 Spe 1:406-430.. The PMAQ-AB became an opportunity to join efforts between government and academia, and to use knowledge in PHC, in addition to research expertise²2 Pellegrini Filho A. Pesquisa em saúde, política de saúde e equidade na América Latina. Cienc Saude Colet. 2004; 9(2):339-350.,⁵5 Trostle J, Bronfman M, Langer A. How do researchers influence decision makers? Case studies of Mexican policies. Health Policy Plan. 1999; 14(2):103-114.. This is especially important considering that evaluation is a key component for the implementation of the program and the subsequent transfer of federal financial resources to municipalities, corresponding to the performance achieved in the evaluative process.

Scientific research on PMAQ-AB has been limited to analyzing aspects related to its theoretical and methodological framework, or results observed from the evaluations⁶6 Rodrigues V, Santos CRI, Pereira MU. A experiência de planejar e operacionalizar o PMAQ-AB no estado do Acre. Saude Debate. 2014; 38 Spe:173-181.

7 Melo DC, Rocha AARM, Aleluia IRS. Avaliação externa do PMAQ-AB: elementos facilitadores e limitantes em capital do Nordeste brasileiro. Rev Eletronica Gest Saude. 2017; 8(1):3-17.

8 Barbosa A. PMAQ-AB nas equipes de Saúde da Família, do distrito de saúde leste, em Campinas-SP [dissertação]. Campinas: Universidade Estadual de Campinas; 2015.

9 Muramoto FT. Repercussões da avaliação PMAQ-AB no processo de trabalho das equipes de Saúde da Família [dissertação]. Ribeirão Preto: Universidade de São Paulo; 2017.-¹⁰10 Sampaio J, Moraes MN, Marcolino EC, Castro ID, Gomes LB, Clementino FS. PMAQ-AB: a experiência local para a qualificação do programa nacional. Rev Enferm UFPE. 2016; 10 Supl 5:4318-4328.. However, no studies yet explore in depth the role of IEPs in cooperation as a key element of analysis in the context of the government program.

In order to understand the aspects related to this cooperation in the Policy Analysis level, it is required to investigate the institutional and political phenomena associated with the devices that structure the program. Historical Neoinstitutionalism represents a useful approach for understanding the role of “institutions,” defined as formal and informal mechanisms that shape the behavior of actors in the formulation, decision, and implementation of public policies¹¹11 Hall PA, Rosemary TRC. As três versões do neoinstitucionalismo. Lua Nova. 2003; (58):194-224.,¹²12 Pierson P, Skocpol T. Historical institutionalism in contemporary political science. In: Katznelson I, Miller H, editors. Political science: the state of the discipline. Nova York: W.W. Norton; 2002. p. 693-721., in historical contexts that shape the trajectory of these initiatives in an important area of the SUS.

From a certain angle of analysis, the shape of the political interactions of the institutional actors reflects the combination of efforts and interests happening in this cooperation within the scope of the SUS. Therefore, institutions matter from the perspective of change or maintenance of the status quo, which must be analyzed associated with historical facts, in a longitudinal sequence¹¹11 Hall PA, Rosemary TRC. As três versões do neoinstitucionalismo. Lua Nova. 2003; (58):194-224.,¹²12 Pierson P, Skocpol T. Historical institutionalism in contemporary political science. In: Katznelson I, Miller H, editors. Political science: the state of the discipline. Nova York: W.W. Norton; 2002. p. 693-721. in activities within the public health sector. There is still scarcity of this deeper scientific analysis.

This study analyzes the role of IEPs in the frame of the institutional cooperation with the MoH for the implementation of PMAQ-AB, from the perspective of Historical Neoinstitutionalism, considering that the context and the actors involved in this process are able to orient the strategies adopted in each circumstance, depending on the public agents’ choices and the institutional characteristics of academia and SUS.

Methodology

The historical neo-institutionalism perspective, as a model of policy analysis, makes it possible to investigate aspects involving the political-institutional dynamics of public policies in the SUS, with emphasis on the historical process¹¹11 Hall PA, Rosemary TRC. As três versões do neoinstitucionalismo. Lua Nova. 2003; (58):194-224.,¹²12 Pierson P, Skocpol T. Historical institutionalism in contemporary political science. In: Katznelson I, Miller H, editors. Political science: the state of the discipline. Nova York: W.W. Norton; 2002. p. 693-721.. This study adopted the neo-institutionalism approach to understand the influence of the actors and the political-institutional context in the process of policy-building, in order to identify the factors that conditioned the definition of the interests of SUS political actors and the decisions regarding the program, as performed by other authors¹³13 Ouverney AM, Fleury S. Polarização federativa do SUS nos anos 1990: uma interpretação histórico-institucionalista. Rev Adm Publica. 2017; 51(6):1085-1103.,¹⁴14 Souza C. Modernização do Estado e construção de capacidade burocrática para a implementação de políticas federalizadas. Rev Adm Publica. 2017; 51(1):27-45..

This qualitative research is based on a case study that analyzes the institutionality and the set of actions performed by the IEPs in PMAQ-AB. The research was developed in two stages, combining the following research methods: document analysis and interviews¹⁵15 Yin PK. Estudo de caso: planejamento e métodos. 5a ed. Porto Alegre: Bookman; 2015..

In the first stage, the research selected official documents on PMAQ-AB, published from 2011 to 2019, the development period of the three evaluative cycles. As these documents contained little information related to institutional cooperation, semi-structured interviews were conducted aiming to obtain greater detail of the processes and experience, especially regarding the role of IEPs during the implementation period of the program.

A script was used for the interviews for each respondent profile. We chose to interview key players and public agents involved in the decision-making process regarding the march of PMAQ-AB within this institutional cooperation, considering that they are individuals with key information about this process. Regarding the MoH, the interviews involved individuals with management positions; related to the IEPs, it involved project coordinators of the main institutions (Table 2), i.e., those who received federal financial resources and led the operational processes for project execution.

Seven interviews were conducted with the key players - three from the MoH and four from the IPEs -, and they were interrupted when finding redundant information, reaching theoretical saturation¹⁶16 Patton MQ. Qualitative research & evaluation methods integrating theory and practice. 4a ed. Thousand Oaks: Sage Publications; 2014.. The interviews were transcribed and stored electronically, along with the other selected documents. The data approach was based on content analysis¹⁷17 Bardin L. Análise de conteúdo. São Paulo: Edições 70; 2015. performing fluctuating reading, followed by document exploration, in which the analytical categories were identified (chart 3). In the final stage, the previous steps enabled an interpretation of the content and understanding of the meanings.

From theoretical formulation to the execution of the external evaluation

According to the interviewees, the cooperation was directed towards the external evaluation of PMAQ-AB in the three cycles. In the first cycle, simultaneously with this evaluation, the IEPs carried out a census of Basic Health Units (BHU) in the country, due to the federal government’s interest in obtaining data to direct the financial resources of the BHU Requalification Program, aimed towards improving the physical structure of the units. According to the Participant MS-2

The interviewees highlighted the inherent challenges arising from a process of this magnitude. Participant IEP-2 recalled that it was a “huge” process, unprecedented, in which the IEPs acquired expertise in developing census studies in a country with a large territory, with much geographical and political diversity, since each evaluation cycle involved approximately 40,000 UBS, owing to the fact that the adherence of teams to PMAQ-AB reached more than 90%.

The participants remarked the diversity of characteristics of the municipalities and the realities of the Brazilian PHC, added to the size of the work, generating the need for institutional mobilization to aggregate partners from different IEPs in the country, in order to put together decentralized teams, although the administrative and operational burden remained at the main university, according to evidence present in the following speech:

Those IEPs responsible for more than one state, with a large territorial extension and areas of difficult access, with municipalities with political-institutional disparities, having thousands of health teams to visit, established consortia with local institutions of the same nature (Frame 1), resulting in more than 40 IEPs involved in the project, according to Participant IEP-4.

Participant IEP-4 stated that the cooperation “was structured based on thinking about what was important to evaluate in PHC to compose an evaluation matrix. In this process, the PHC Network mobilized the expertise of its management committee to collaborate with the definition of key questions that guided the evaluation. These guidelines were the theoretical ground of the program and the design of the evaluative instruments to measure the teams’ performance¹⁶16 Patton MQ. Qualitative research & evaluation methods integrating theory and practice. 4a ed. Thousand Oaks: Sage Publications; 2014., being the result of this institutional approach of the MoH with IEPs in the context of evidence-informed policies.

The following frame consolidates the activities carried out by the IEPs, as verified in the document analysis and evidenced in the interviews.

During the first cycle of PMAQ-AB, when the external evaluation and the census happened, it was necessary to adapt the action mechanisms and the evaluative parts. As an example, the construction of the evaluative instrument made it necessary to contemplate the objectives of both programs. However, in the fieldwork, the IEPs needed to adopt logistical planning to deploy their teams to municipalities where they would perform the PMAQ-AB evaluation, while in others, only the census was completed⁶6 Rodrigues V, Santos CRI, Pereira MU. A experiência de planejar e operacionalizar o PMAQ-AB no estado do Acre. Saude Debate. 2014; 38 Spe:173-181.,¹⁸18 Gomes LB, Barbosa MG, Ferla AA. Atenção básica: olhares a partir do programa nacional de melhoria do acesso e da qualidade da atenção básica. Porto Alegre: Rede Unida; 2016.,¹⁹19 Fausto MCR, Fonseca HMS. Rotas da Atenção Básica no Brasil: experiências do trabalho de campo PMAQ-AB. Rio de Janeiro: Saberes; 2013.. In the second and third cycles, there was no census, so the same evaluative tool and fieldwork strategy were used to evaluate all teams.

The activities showed in chart 4 are similar to those evidenced by Rodrigues, Santos, and Pereira⁶6 Rodrigues V, Santos CRI, Pereira MU. A experiência de planejar e operacionalizar o PMAQ-AB no estado do Acre. Saude Debate. 2014; 38 Spe:173-181., Fausto and Fonseca¹⁹19 Fausto MCR, Fonseca HMS. Rotas da Atenção Básica no Brasil: experiências do trabalho de campo PMAQ-AB. Rio de Janeiro: Saberes; 2013.. In all cycles, the operationalization of the external evaluation occurred with the articulation of the visit to the cities, based on previous contact with local managers and negotiation of the work schedule; constitution and organization of the research team; and monitoring of data collection.

The study used technological resources for data collection, such as the mobile application of the evaluation instrument, the External Evaluation Management System and the tablet. The latter required “an administrative process for large-scale purchases” (Participant IEP-1). It also added expertise to generate innovations, such as the “team from the Health Information Technology Laboratory of the Federal University of Rio Grande do Norte, that had the role of developing these technological tools,” according to Participant IEP-2. In the last cycle, monitoring the external evaluation in real time²⁰20 Uchôa SAC, Martiniano CS, Queiroz AAR, Bay Júnior G, Nascimento WG, Diniz IV, et al. Inovação e utilidade: avaliação externa do programa nacional de melhoria do acesso e da qualidade da atenção básica. Saude Debate. 2018; 2 Spe1:100-113. was done through a data panel. These technological resources, which sought to give more agility and capacity to the work and required specific work to ensure its proper functioning²⁰20 Uchôa SAC, Martiniano CS, Queiroz AAR, Bay Júnior G, Nascimento WG, Diniz IV, et al. Inovação e utilidade: avaliação externa do programa nacional de melhoria do acesso e da qualidade da atenção básica. Saude Debate. 2018; 2 Spe1:100-113.,²¹21 Cavalcanti PCS, Oliveira Neto AV, Sousa MF. Uma narrativa sobre o programa nacional de melhoria do acesso e da qualidade na atenção básica. In: Gomes LB, Barbosa MG, Ferla AA, organizadores. Atenção Básica: olhares a partir do Programa Nacional de Melhoria do Acesso e da Qualidade da Atenção Básica. Porto Alegre: Rede Unida; 2016. p. 17-47. were additional results from this cooperation between the MoH and the academia to meet operational needs of PMAQ-AB.

At each cycle, other activities were progressively developed by the IEPs (Frame 2) due to the gaps and difficulties found in the evaluation process, especially after the first cycle. According to the interviewed academics, the approximation with local health managers was a need, highlighted in the governance process and, therefore, its “feasibility was discussed in the National Coordination of External Evaluation, that was the driving group of cooperation” (Participant IEP-2). Participant IEP-4 stated:

Institutional exchanges with local managers happened in heterogeneous ways. In some cases, they were more frequent, with participation of the IEP in “endless negotiations with SUS managers and Health Councils” (Participant IEP-1), carrying out a diversity of activities with managers and health professionals (Frame 3). In other cases, “even when the agendas did not match, for the aims of the operationalization of the external evaluation [...] there was full support from the State and Municipal Health Secretariats” (Participant IEP-2). In these settings, the activities were restricted to the external evaluation for planning and negotiating the fieldwork scripts with local managers.

The interviews indicate that the reasons for this approach with local health managers were aimed mainly at a better understanding and execution of the evaluation. At the same time it was instrumental at reducing tensions originating from this process, mainly related to the political issues that influenced it³3 Cavalcanti P, Fernandez M. Programa de melhoria do acesso e da qualidade da atenção básica: uma análise das principais mudanças normativas. Physis. 2020; 30(3):e300323., especially due to the linkage of financial resources to performance, generating “concerns” for managers and health professionals from local health systems¹⁸18 Gomes LB, Barbosa MG, Ferla AA. Atenção básica: olhares a partir do programa nacional de melhoria do acesso e da qualidade da atenção básica. Porto Alegre: Rede Unida; 2016.,¹⁹19 Fausto MCR, Fonseca HMS. Rotas da Atenção Básica no Brasil: experiências do trabalho de campo PMAQ-AB. Rio de Janeiro: Saberes; 2013..

Participant IEP-1 highlighted “the relevance of the support of academic institutions in the decision-making processes of the MoH, particularly in PHC,” attributing more of this role to IEPs within institutional cooperation. In this sense, Participant MS-4 explained:

The scholars emphasized during the interviews the “intense pace” that the agenda imprinted in political-institutional ways to each cycle of PMAQ-AB. According to Participant IEP-2, “[...] when you look back, you see how big the work was, how many people were involved, the logistics created. The external evaluation is a highly consuming activity for the university.” Therefore, in the absence of this institutional cooperation, this stage of the program would have many operational and legal difficulties to be implemented nationally, due to the organizational characteristics and political-administrative obstacles imposed on PPEs and the MoH alone, as evidenced.

For Participant IEP-1, the formal documents of the MoH restrict the activities performed in the PMAQ-AB Process to the planning and execution of the external evaluation. He stated:

The hardly visible activities make up two strands of Participant IEP-1’s statement. “[...] the first is the herculean process of institutionalization of the partnership in universities, since they do not have a tradition of mobilizing institutional resources for the execution of final activities of public health policies.” Especially in the studied period, the relationship between universities and foundations of support was subject to several changes in federal legislation, “with a predominance of an administrative rationale”. The second refers to the “work” of the IEPs, which was not restricted to the external evaluation, since the “fieldwork” of the research was influenced by “intangible variables” of several dimensions, impacting the process. Furthermore, “the accumulation of evaluative data is not the only purpose of the work in the IEPs”, which need to develop “teaching, research, and extension”.

The expansion of institutional capacity with the support of the IEPs

Participant MS-1 stated that the universities brought several elements for the improvement of the formulation and implementation of the policy, of legitimization of the evaluation process, and of expansion of knowledge production. In his conception,

From the Participant IEP-2 point of view, “universities gave technical and political support” to PMAQ-AB, since the program was not only built by the MoH, but also relied on “serious” and “competent” IEPs, who work for the development of the SUS and accumulate experience in evaluative research over years. In this way, the political-institutional adherence of the IEPs to the cooperation signals that they are “certifying” and issuing a “quality seal” that legitimizes the evaluation, from the perspective of scientific rigor, as well as the expectation of exemption to reduce possible biases in the allocation of public resources linked to the program.

Concurrently, Participant IEP-3 emphasized that the participation of more than 40 universities “all of them recognized from the point of view of their relevance” conferred credibility to the evaluation. For Participant IEP-1, the “academic institutions gave the program internal sustainability and external credibility”. In addition, from his perspective, the support of the IEPs to PMAQ-AB also meant

The IEPs mobilized their full institutional apparatus for the PMAQ-AB process, especially in the execution of the fieldwork of the evaluation, for subsequent use of the data by the MoH in the certification, not withstanding its use for scientific studies associated with the interests of academia⁷7 Melo DC, Rocha AARM, Aleluia IRS. Avaliação externa do PMAQ-AB: elementos facilitadores e limitantes em capital do Nordeste brasileiro. Rev Eletronica Gest Saude. 2017; 8(1):3-17.. However, it is important to highlight some problems related to the complexity of this process, such as the fear of managers and professionals in the teams to receive the interviewers⁷7 Melo DC, Rocha AARM, Aleluia IRS. Avaliação externa do PMAQ-AB: elementos facilitadores e limitantes em capital do Nordeste brasileiro. Rev Eletronica Gest Saude. 2017; 8(1):3-17.,¹⁹19 Fausto MCR, Fonseca HMS. Rotas da Atenção Básica no Brasil: experiências do trabalho de campo PMAQ-AB. Rio de Janeiro: Saberes; 2013., due to initially thinking that the assessment would be carried out without the proper knowledge of local realities, putting the results at risk¹⁹19 Fausto MCR, Fonseca HMS. Rotas da Atenção Básica no Brasil: experiências do trabalho de campo PMAQ-AB. Rio de Janeiro: Saberes; 2013..

Credibility of the interviewers regarding their qualification and ability to generate reliable and representative data of reality²⁰20 Uchôa SAC, Martiniano CS, Queiroz AAR, Bay Júnior G, Nascimento WG, Diniz IV, et al. Inovação e utilidade: avaliação externa do programa nacional de melhoria do acesso e da qualidade da atenção básica. Saude Debate. 2018; 2 Spe1:100-113. was also a matter of concern. The criticism related to variations in interviewer strategies and posture⁸8 Barbosa A. PMAQ-AB nas equipes de Saúde da Família, do distrito de saúde leste, em Campinas-SP [dissertação]. Campinas: Universidade Estadual de Campinas; 2015.,⁹9 Muramoto FT. Repercussões da avaliação PMAQ-AB no processo de trabalho das equipes de Saúde da Família [dissertação]. Ribeirão Preto: Universidade de São Paulo; 2017. highlights the heterogeneity of profiles as a consequence of different selection, training, and hiring processes by IEPs⁶6 Rodrigues V, Santos CRI, Pereira MU. A experiência de planejar e operacionalizar o PMAQ-AB no estado do Acre. Saude Debate. 2014; 38 Spe:173-181.,²⁰20 Uchôa SAC, Martiniano CS, Queiroz AAR, Bay Júnior G, Nascimento WG, Diniz IV, et al. Inovação e utilidade: avaliação externa do programa nacional de melhoria do acesso e da qualidade da atenção básica. Saude Debate. 2018; 2 Spe1:100-113., which may have contributed to a negative evaluation of local stakeholders regarding the process. On the other hand, there are accounts of manipulation and modification of reality by managers and professionals in the evaluation teams, as well as about the weak participation and understanding of these actors about the program¹⁰10 Sampaio J, Moraes MN, Marcolino EC, Castro ID, Gomes LB, Clementino FS. PMAQ-AB: a experiência local para a qualificação do programa nacional. Rev Enferm UFPE. 2016; 10 Supl 5:4318-4328.,¹⁸18 Gomes LB, Barbosa MG, Ferla AA. Atenção básica: olhares a partir do programa nacional de melhoria do acesso e da qualidade da atenção básica. Porto Alegre: Rede Unida; 2016.,¹⁹19 Fausto MCR, Fonseca HMS. Rotas da Atenção Básica no Brasil: experiências do trabalho de campo PMAQ-AB. Rio de Janeiro: Saberes; 2013..

In order to mitigate questions about the conflicts of interest associated with external evaluation, there were measures in order to avoid linking evaluators and evaluated during the selection process²⁰20 Uchôa SAC, Martiniano CS, Queiroz AAR, Bay Júnior G, Nascimento WG, Diniz IV, et al. Inovação e utilidade: avaliação externa do programa nacional de melhoria do acesso e da qualidade da atenção básica. Saude Debate. 2018; 2 Spe1:100-113.. The IEPs were also given autonomy to perform the fieldwork in order to avoid the need of municipal financial support and, consequently, political interference in the process. In the first cycle of PMAQ-AB, the national negotiation between the federative entities provided logistical support for lodging and travel of the interviewer teams within the municipality by the local management. In the other cycles, the MoH and the IEPs were responsible for the fieldwork costs. Exceptionally, the municipality could contribute with the displacement of interviewers to the local BHUs.

The fact that the MoH, responsible for implementing the public health policy, did not have the institutional capacity to operationalize the external evaluation of PMAQ-AB led to cooperation with the academia, in order to mobilize knowledge, institutions and organizations capable of implementing federalized policies, as pointed out by Souza¹⁴14 Souza C. Modernização do Estado e construção de capacidade burocrática para a implementação de políticas federalizadas. Rev Adm Publica. 2017; 51(1):27-45.. This formal cooperation between the federal government and IEPs was essential to ensure the implementation of the program during three cycles.

The new institutional arrangement created expanded the institutional capacity for evaluation of intergovernmental initiatives in the SUS, through joint efforts from IEPs that have, over the years, played a relevant role in the structuring of PHC and the consolidation of evaluative research in the country, especially with support from the PHC Network⁴4 Rede de Pesquisa em Atenção Primaria à Saúde da ABRASCO. Contribuição para uma agenda política estratégica para a Atenção Primária à Saúde no SUS. Saude Debate. 2018; 2 Spe 1:406-430.,²²22 Andrade HS, Bragante I. A trajetória da Rede de Pesquisa em Atenção Primária à Saúde da Abrasco. Saúde Debate. 2018; 42 Spe1:396-405..

This institutional cooperation signals the strengthening of the democratic process in the construction of health policy through flexible arrangements between institutions organized in collaborative networks, following the example of other initiatives that constitute new trends and opportunities for integration between science and society in the context of public health policies in Latin America, as described by Pellegrini Filho²2 Pellegrini Filho A. Pesquisa em saúde, política de saúde e equidade na América Latina. Cienc Saude Colet. 2004; 9(2):339-350..

IEPs have social functions that reflect interests, values, culture, among other particular characteristics²2 Pellegrini Filho A. Pesquisa em saúde, política de saúde e equidade na América Latina. Cienc Saude Colet. 2004; 9(2):339-350. that do not allow them to be confused with a service provider. This explains why their participation in the program was related to a higher degree of neutrality, legitimacy and credibility for a process of this nature.

Connected with this argument, the analysis of the formal approach has relevant implications for the interpretation of the institutionalization of a national evaluation of this magnitude in the SUS, even more so with the transfer of federal funds to municipalities conditioned to the performance of health teams in the evaluation process over a period of several years.

During the cooperation activities, the IEPs contributed to the theoretical foundation, pointing out elements of support for decision making and stimulating reflections that provide opportunities for collective learning and knowledge production; as well as in innovation, with the operationalization of the evaluation process at the national level²⁰20 Uchôa SAC, Martiniano CS, Queiroz AAR, Bay Júnior G, Nascimento WG, Diniz IV, et al. Inovação e utilidade: avaliação externa do programa nacional de melhoria do acesso e da qualidade da atenção básica. Saude Debate. 2018; 2 Spe1:100-113.. Therefore, even though this evaluation does not represent scientific research, it certainly benefited from academic knowledge adjusted to the singularities and diversities that characterize Brazilian PHC. Given the complexity of the project, the multiplicity of actions developed and situations showed through this research evidences the contribution of academia to problem solving and policy improvement²2 Pellegrini Filho A. Pesquisa em saúde, política de saúde e equidade na América Latina. Cienc Saude Colet. 2004; 9(2):339-350.,⁵5 Trostle J, Bronfman M, Langer A. How do researchers influence decision makers? Case studies of Mexican policies. Health Policy Plan. 1999; 14(2):103-114..

The dynamics of the research and policy process went hand in hand in the PMAQ-AB, with possible bilateral benefits, as advocated by Elias and Patroclo²³23 Elias FTS, Patroclo MAA. Utilização de pesquisas: como construir modelos teóricos para avaliação? Cienc Saude Colet. 2005; 10(1):215-227.. As managers had the aim to implement the policy, they approached the academia and this opportunity allowed greater integration of science to the political process in the SUS²2 Pellegrini Filho A. Pesquisa em saúde, política de saúde e equidade na América Latina. Cienc Saude Colet. 2004; 9(2):339-350., in a different perspective from that observed in traditional public administration. On the other hand, for the academics, it allowed an evaluation of PHC from different angles, favoring the generation of new knowledge and greater proximity with managers and health professionals¹⁸18 Gomes LB, Barbosa MG, Ferla AA. Atenção básica: olhares a partir do programa nacional de melhoria do acesso e da qualidade da atenção básica. Porto Alegre: Rede Unida; 2016.,¹⁹19 Fausto MCR, Fonseca HMS. Rotas da Atenção Básica no Brasil: experiências do trabalho de campo PMAQ-AB. Rio de Janeiro: Saberes; 2013.. As a bonus, it inserted the researchers in the political arena of SUS decision-making.

Although there is an approximation of interests among the cooperating parties, the external evaluation process faced technical-political challenges that required adjustments in strategies and configurations of new institutional arrangements¹¹11 Hall PA, Rosemary TRC. As três versões do neoinstitucionalismo. Lua Nova. 2003; (58):194-224. to create consensus and solve governance conflicts, considering obstacles that permeate the relationships between the field of public policy and academia, as stated by Pelegrini Filho²2 Pellegrini Filho A. Pesquisa em saúde, política de saúde e equidade na América Latina. Cienc Saude Colet. 2004; 9(2):339-350. and Trostle, Bronfman and Langer⁵5 Trostle J, Bronfman M, Langer A. How do researchers influence decision makers? Case studies of Mexican policies. Health Policy Plan. 1999; 14(2):103-114..

Academic institutions have become active in the landscape of political dispute among the institutional players, in the context of program formulation and implementation, subject to the complex decision-making process in the deliberative forums of the SUS. This process involves compliance with current regulations and articulation among the intervening actors, especially in the sphere of tripartite (Federal, State, Municipal) governance, where national negotiations on health policies take place²⁴24 Cavalcanti P, Fernandez M. A tomada de decisão em políticas públicas de saúde: uma revisão sistêmica a partir de estudos realizados no Brasil. In: Gurgel Junior GD, Pacheco HF, Oliveira SRA, Santos FAS, organizadores. Inovações da gestão pública no SUS: uma abordagem das iniciativas no processo de reforma institucional. Recife: UFPE; 2021. p. 41-72..

Similar to other health sector reform processes that have happened in the country, it can be observed that the dynamics involved a plurality of actors, convergences, divergences, uncertainties, difficulties and limitations, but also opportunities, possibilities and adjustments of strategies, reflecting a crucial exercise in the face of political and technical challenges for the implementation of this program¹³13 Ouverney AM, Fleury S. Polarização federativa do SUS nos anos 1990: uma interpretação histórico-institucionalista. Rev Adm Publica. 2017; 51(6):1085-1103.,²⁵25 Silva SF. Municipalização da saúde e poder local: sujeitos, atores e políticas. São Paulo: Hucitec; 2001.. The PMAQ-AB can be seen as a prime example of a process of institutional change influenced by the second generation of public sector reforms affecting the SUS.

Therefore, this evaluation suffered multiple and often contradictory determinants, with changes that are related to the needs identified in the process; and circumstantial decisions, according to negotiations with the other federative entities and IPEs. However, external and internal factors to the government and the IPEs have shown the need to reorient objectives and make implementation strategies more flexible in a configuration different from the initial plan or expectation.

The implementation period of the program coincided in time with the occurrence of historical events, such as the emergence of a political and economic crisis in Brazil²⁶26 Machado CV, Lima LD, Baptista TWF. Políticas de saúde no Brasil em tempos contraditórios: caminhos e tropeços na construção de um sistema universal. Cad Saude Publica. 2017; 33 Suppl 2:143-161., associated with heated electoral disputes and the impeachment of President Dilma Rousseff. Such events caused institutional ruptures and reconfigured the positions in the federal government³3 Cavalcanti P, Fernandez M. Programa de melhoria do acesso e da qualidade da atenção básica: uma análise das principais mudanças normativas. Physis. 2020; 30(3):e300323.. From these events emerged new political and economic conjuncture, which impacted the directions and format of social policies, especially in the health field.

This context contributed to the formation of a new trajectory of dependency¹¹11 Hall PA, Rosemary TRC. As três versões do neoinstitucionalismo. Lua Nova. 2003; (58):194-224.,¹²12 Pierson P, Skocpol T. Historical institutionalism in contemporary political science. In: Katznelson I, Miller H, editors. Political science: the state of the discipline. Nova York: W.W. Norton; 2002. p. 693-721., and the PMAQ-AB was discontinued in 2019, being replaced by another pay-for-performance initiative in PHC, instituted by the Previne Brazil Program (Ordinance n. 2,979, of November 12, 2019). This meant breaking apart the institutional cooperation, with repercussions for policy management and the research agenda in the area²⁷27 Rede de Pesquisa em Atenção Primaria à Saúde da ABRASCO. Contribuição dos pesquisadores da Rede APS ao debate sobre as recentes mudanças na política de atenção primária [Internet]. Rio de Janeiro: ABRASCO; 2019 [citado 10 Set 2020]. Disponível em: https://www.abrasco.org.br/site/eventos/congresso-brasileiro-de-ciencias-sociais-e-humanas-em-saude/contribuicao-dos-pesquisadores-da-rede-aps-ao-debate-sobre-as-recentes-mudancas-na-politica-de-atencao-primaria/43125/
https://www.abrasco.org.br/site/eventos... . This rupture had implications, considering that this approximation between government and academia made it possible to obtain important information to subsidize evidence-based decision making, in addition to the expansion of research groups as well as numerous publications in the area⁴4 Rede de Pesquisa em Atenção Primaria à Saúde da ABRASCO. Contribuição para uma agenda política estratégica para a Atenção Primária à Saúde no SUS. Saude Debate. 2018; 2 Spe 1:406-430.,²⁷27 Rede de Pesquisa em Atenção Primaria à Saúde da ABRASCO. Contribuição dos pesquisadores da Rede APS ao debate sobre as recentes mudanças na política de atenção primária [Internet]. Rio de Janeiro: ABRASCO; 2019 [citado 10 Set 2020]. Disponível em: https://www.abrasco.org.br/site/eventos/congresso-brasileiro-de-ciencias-sociais-e-humanas-em-saude/contribuicao-dos-pesquisadores-da-rede-aps-ao-debate-sobre-as-recentes-mudancas-na-politica-de-atencao-primaria/43125/
https://www.abrasco.org.br/site/eventos... .

Final considerations

Academic institutions, through formal cooperation agreements with the MoH, have coordinated a partnership with dozens of other related institutions throughout the country with the objective of implementing a government program. The panorama presented in this article allows us to affirm that this cooperation made possible the execution of an unprecedented evaluative research carried out and implemented in the SUS. Undoubtedly, this process reaffirmed Brazil as a hub for research in Primary Care, given the wealth of experiences in health care, system management, teaching, and research³3 Cavalcanti P, Fernandez M. Programa de melhoria do acesso e da qualidade da atenção básica: uma análise das principais mudanças normativas. Physis. 2020; 30(3):e300323., with plenty of lessons to offer.

However, it is noteworthy that several notorious criticisms about the problems and contradictions related to the evaluation process, especially because of its association with payment for performance, were not evidenced in this research. This aspect may be related to the choice of interviewees, which did not include local actors affected by the evaluation process. Another limitation is the number of interviewees, which, although may be considered satisfactory due to it reaching the theoretical saturation point, nevertheless does not allow the generalization of the findings. Moreover, the scarcity of research on this institutional cooperation limited the comparison of the results with other studies. It is suggested that future research could explore the dimension of local reality in the context of PMAQ-AB implementation and elements related to this institutional cooperation in SUS.

Using the Historical Neoinstitutionalism approach, this article shows that the PMAQ-AB and its evaluation result from a historical process whose previous evaluative experiences enabled the accumulation of knowledge and connected actors focused on the development of the SUS. It also reveals that the implementation of the program was developed under the influence of the political context of the time, as well as by the interventions guided by the characteristics of the institutions. In this scenario, the IEPs constituted themselves as stakeholders in the decentralized implementation of the program for about a decade.

Regarding the challenges imposed on public policies, this study contributes to a better understanding of the complexity of the dynamics that permeate the formulation and implementation of evaluation processes and payment for performance. Throughout different national contexts in public health management, they should be considered as the result of institutional conformations, especially those related to the historical trajectory of the institutions and actors involved with the initiative.

References

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