Abstract

Regionalization is one of the great challenges faced since the municipalization of health in Brazil and, once consolidated, it enables the structuring of a regional scale that enhances territories. Among the organizational arrangements for regionalization, the Public Health Consortium (PHC) is positioned, which must deal not only with the sum of individualities, but with collective action. This study aims to analyze the perception of health managers at the municipal level in the Middle Paranapanema Health Region of Northern Paraná, Brazil, regarding the role of the PHC in the regionalization process. The research had a qualitative, exploratory approach, which used interviews and focus groups for data collection, which were submitted to the method of discourse analysis. The results present both the conditions that limit collective action and the conditions that favor it. With this, some limitations in the consortium's performance are unveiled, highlighting the confusion about its role and the conflicts of interest that arise from this performance, in addition to its collaborative and supportive character, which positions it as a space to exercise cooperation. With that, the joint action initiatives demonstrate the empowerment of managers, resulting in the strengthening of regionalization.

Keywords:
Regional Health Planning; Public Health Consorcium; Health Management.

Introduction

In view of the redemocratization in the country, in view of the Health Reform Movement and the advent of the Unified Health System (SUS), a new conformation in health management is proposed, so that the municipal entity is responsible for consolidating the reform proposals (BRAZIL, 2011Brasil . Decreto nº 7.508, de 28 de junho de 2011. Diário Oficial da República Federativa do Brasil. Brasília, 2011.). With this, the burden of municipal management points to the exhaustion of individual initiatives of the municipalities and to the need to consolidate regionalization.

Regionalization is one of the biggest challenges faced by the SUS since the municipalization of health in Brazil, and for its consolidation advances in the relationships between entities in the management spheres are needed. Considering the relevance of the federative relationship for the SUS and the emergence of several initiatives of federative arrangements, the Public Health Consortia (PHC) are shown as an institutional arrangement to be considered with regard to strengthening regionalization (CARLOS; TREVAS, 2013CARLOS, V.; TREVAS, P. Consórcio público e o federalismo brasileiro. In: CHERUBINE, M.; TREVAS, V. (Orgs.). Consórcios públicos e as agendas do Estado brasileiro. São Paulo: Editora Fundação Perseu Abramo, 2013. 144 p. ).

There is evidence in the scientific literature that PHC promoted an increase in efficiency and quality, above all, in specialized services (PEIXOTO, 2000PEIXOTO, M. P. Consórcios intermunicipais de saúde: perspectivas de avaliação de algumas experiências, CIS Penápolis, CIS Amunpar, CIS Teles Pires. Brasília: OPAS e Secretaria de Políticas de Saúde/Ministério da Saúde, 2000.; GONTIJO et al., 1994GONTIJO, L. T. et al. Penápolis: Relato de experiência. Espaço para a Saúde, v. 3, n. 3, p. 122-36, 1994.). Another study points out that the PHC technically contributes to the municipalities in terms of solving problems without the municipality losing its autonomy (VAZ, 1997VAZ, J. C. Consórcios Intermunicipais. Boletim Dicas Pólis-Ildesfes: AA - Ideias para Ação Municipal, 1997.). In addition, other research highlights the role of the PHC as a promoter of economic development, optimization of resources, fixation of the population in small localities and reduction of regional inequalities, promoted through the federative conjugation of efforts in consortium action (ENDLICH, 2017ENDLICH, A. M. Cooperações intermunicipais: alguns aportes. Maringá: PGE-UEM, 2017.; MENDONÇA ; ANDRADE, 2018MENDONÇA, F. F.; ANDRADE, S. K. A. V. Consórcio Público de Saúde como arranjo para relação federativa e o processo de regionalização. Redes. Santa Cruz do Sul, v. 23, n. 3, p. 206-224, set. 2018. ; LIMA, 2000LIMA, A. P. G. Os Consórcios Intermunicipais de Saúde e o Sistema Único de Saúde. Cad. Saúde Pública, Rio de Janeiro, v. 16, n. 4, p. 985-996, dez. 2000. ).

Considering the notes brought by the literature and the need to find advance strategies for the regionalization process, which allows structuring a regional scale that enhances territories, it is important to analyze the role of the PHC, based on the reflection on its history in Brazilian federalism and in SUS regulations. Furthermore, as Paraná is one of the states with the longest tradition of organizing consortia, it is important to understand how the PHC works to enhance this process of regional strengthening. Thus, this study aimed to analyze the perception of health managers at the municipal level in the Middle Paranapanema Health Region of Northern Paraná about the role of the PHC in the regionalization process.

Theoretical Reference

The theoretical basis for the discussion of this research topic is supported by the history of federalism in Brazil and, more recently, by the SUS, on the one hand, and on the other, in the concept of collective action (CA), which supports reflections on the role of consortia facing the challenges for regionalization.

The public health consortium in Brazilian federalism and the SUS

The consortium action takes part in the history of federalism in Brazil, being wagered in the first Federal Constitution (CF) of 1891 as contracts between entities. In 1934, the 2nd FC did not promote federative cooperation, as pointed out by Losada (apud SILVEIRA, 2002SILVEIRA, A. P. S. A cooperação intergovernamental no Estado composto brasileiro: análise jurídico-constitucional. In: CONGRESSO INTERNACIONAL DEL CLAD SOBRE LA REFORMA DEL ESTADO Y DE LA ADMINISTRACIÓN PÚBLICA, VII. Anais..., Lisboa, Portugal, 8-11 out. 2002. 177 p.). The Federal Constitution of 1937 maintained federalism only in name (LOSADA, 2008LOSADA, P. R. O Comitê de Articulação Federativa: instrumento de coordenação e cooperação intergovernamental de políticas públicas no Brasil. In: CONGRESO INTERNACIONAL DEL CLAD SOBRE LA REFORMA DEL ESTADO Y DE LA ADMINISTRACIÓN PÚBLICA, XIII., Anais..., Buenos Aires, Argentina, 4-7 nov. 2008. ) and provided for consortia as legal entities under public law. The 5th CF, of 1967, establishes that the consortia are mere collaboration pacts, without legal personality. In the 1980s, the first PHC appeared in Brazil and the 6th Federal Constitution (CF/1988) recognized municipalities and states as federative entities, placing them in the scope of the SUS: “Art. 241. The Union, the States, the Federal District and the Municipalities shall regulate, by law, public consortia and cooperation agreements between federated entities [...]”.

Although introduced to the constitutional text through Constitutional Amendment 19/1998 (BRASIL, 1998BRASIL . Constituição (1998). Emenda constitucional nº 19, de 04 de junho de 1998. Modifica o regime e dispõe sobre princípios e normas da Administração Pública e dá outras providências. Diário Oficial da União, Brasília, 05 jun. 1998.) - proposed in 1995 -, the first infra-constitutional elements pointed to consortia. Among them, the Organic Laws of the SUS (BRASIL, 1990aBRASIL. Lei n. 8.080, de 19 de setembro de 1990a. Regula, em todo o território nacional, as ações e serviços de saúde e dá outras providências. Diário Oficial da União. 20 set 1990., ^1990bBRASIL.. Lei n. 8.142, de 28 de dezembro de 1990b. Dispõe sobre a participação da comunidade na gestão do Sistema Único de Saúde (SUS) e sobre as transferências intergovernamentais de recursos financeiros na área da saúde e dá outras providências. Diário Oficial da União. 31 dez 1990.) of 1990, reinforce that the municipalities will be able to form consortia for the development of health actions.

In this sense, the Basic Operational Norms, including NOB 01/91, allow the creation of consortia, which values ​​municipal autonomy (PEREIRA, 2009PEREIRA, A. M. M. Dilemas federativos e regionalização em saúde: o papel do gestor estadual do SUS em Minas Gerais. Dissertação (Mestrado) - Escola Nacional de Saúde Pública, Fundação Oswaldo Cruz, Rio de Janeiro, 2009. ; BRASIL, 1991BRASIL.. Ministério da Saúde. Resolução INAMPS nº 258, de 17 de julho de 1991 (reedição). Normativa Operacional Básica nº 01/91. Boletim de Serviço do INAMPS. Brasília, 1991.). NOB 96 points to the organization of the health system, highlighting the risk of atomization of the SUS, when the municipality is led to believe that it should act as autonomously as possible (BRASIL, 1996Brasil.. Ministério da Saúde. Portaria nº 2.203 de 05 de novembro de 1996. Normativa Operacional Básica nº 01/96. Diário Oficial da República do Brasil. 1994 nov. 11; Seção 1. p. 37.; FLEURY, 2006FLEURY, S. Democracia, descentralização e desenvolvimento: Brasil e Espanha. Rio de Janeiro: Editora FGV, 2006.), representing a threat to uniqueness of the system. As an antidote to these risks, the regulation sees the need to integrate and modernize municipal systems.

The following year, the Ministry of Health emphasizes the creation of the PHC from the document The Year of Health in Brazil (BRASIL, 1997aBRASIL.. O Ano da Saúde no Brasil. Ações e Metas Prioritárias. Ministério da Saúde. Brasília, mar. 1997a. 16p.) and edits the manual The Consortium and Municipal Management in Health, which points to consortia as a tool for articulation between municipal systems, indicating the consortium as an efficient mechanism to encourage municipalities to assume municipal management (BRASIL, 1997bBRASIL.. O consórcio e a gestão municipal em saúde. Brasília: Ministério da Saúde. 1997b. 32p.). In the manual:

One of the first documents that instrumentalizes regionalization is the Operational Norm for Health Care (NOAS), published in 2001 and reissued the following year. But the regulation does not mention public consortia. Even so, the municipalities continued to form consortia through administrative associations. With this, the work of the Federative Articulation Committee (CAF) resulted in Federal Law No. 11.107/2005, known as the Public Consortia Law (LCP), which conceptualizes public consortia as institutional arrangements for federative cooperation and coordination (BRASIL, 2005).

The LCP, regulated by Federal Decree No. 6107/2007, established that the public consortium is voluntary and deals with instruments for the practice of inter-municipal cooperation (LACZYNSKI; ABRUCIO, 2013LACZYNSKI, P.; ABRUCIO, F. L. Desigualdade e Cooperação Federativa: um novo olhar para a discussão dos consórcios. In: CHERUBINE, M.; TREVAS, V. (Orgs.). Consórcios públicos e as agendas do Estado brasileiro. São Paulo: Editora Fundação Perseu Abram o, 2013. 144p.). In addition, they establish the routines for the constitution of public consortia through the protocol of intentions approved by the Legislative Chamber of the respective entities, including: the object of the consortium, the method of apportionment, the purpose, area of ​​operation, legal personality, among others, which will constitute the consortium contract. In the meantime, the Pact for Health (PS), published in 2006, is presented as a set of reforms and proposes innovations (BRASIL, 2006), contemplating the PHC in a restricted way to its monitoring process, identified as a task of the States.

Despite the innovations, there were still difficulties that prevented the use of consortia with the necessary legal certainty. Therefore, the Law on Consortia and the decree that regulates it play an important role in the historical context of the consortium action in Brazil, as they adapt the legislation to the reality of cooperative federalism (FONSECA, 2013). However, there were still gaps in the regionalization process and Federal Decree No. 7,508/2011, which regulates Federal Law No. 8.080/1990 and presents instruments for shared and solidary management, is published (CARVAHO et al., 2017).

Although the decree establishes the Regional Inter-Management Commission (RIC) for articulation at the regional level, the PHC were not included in the context of support to management in this space, making it difficult to organize strategies and actions through consortia. On the other hand, studies showed evidence that, from the PHC, there was an increase in the efficiency and quality of specialized services (PEIXOTO, 2000PEIXOTO, M. P. Consórcios intermunicipais de saúde: perspectivas de avaliação de algumas experiências, CIS Penápolis, CIS Amunpar, CIS Teles Pires. Brasília: OPAS e Secretaria de Políticas de Saúde/Ministério da Saúde, 2000.; GONTIJO et al., 1994GONTIJO, L. T. et al. Penápolis: Relato de experiência. Espaço para a Saúde, v. 3, n. 3, p. 122-36, 1994.). Complementarily, consortia are administrative and political resources, as they increase the capacity of a group of municipalities to present solutions to common problems, without losing their autonomy (VAZ, 1997VAZ, J. C. Consórcios Intermunicipais. Boletim Dicas Pólis-Ildesfes: AA - Ideias para Ação Municipal, 1997.).

In addition, consortia are promoters of economic development, with optimization of resources and the consequent fixation of populations in small locations, providing quality of life for people (ENDLICH, 2017ENDLICH, A. M. Cooperações intermunicipais: alguns aportes. Maringá: PGE-UEM, 2017.; MENDONÇA; ANDRADE, 2018MENDONÇA, F. F.; ANDRADE, S. K. A. V. Consórcio Público de Saúde como arranjo para relação federativa e o processo de regionalização. Redes. Santa Cruz do Sul, v. 23, n. 3, p. 206-224, set. 2018. ). Another positive aspect is the reduction of regional inequalities, promoted through the federative conjugation of efforts in consortium action (LIMA, 2000LIMA, A. P. G. Os Consórcios Intermunicipais de Saúde e o Sistema Único de Saúde. Cad. Saúde Pública, Rio de Janeiro, v. 16, n. 4, p. 985-996, dez. 2000. ). The results of the implementation of the PHC in the practice of the federative relationship enabled new roles for the municipalities, enhancing the political strength and technical capacity of these managers (ENDLICH, 2017).

In Brazil, in 2015, there were 3,691 municipalities participating in public consortia (IBGE, 2016), representing 66.2% of the total number of municipalities. Of the total, 2,800 developed actions in the health area, 95.4% being exclusively inter-municipal. Of the total number of municipalities in the healthcare area, only 122 (about 4%) had a population base above 100,000 inhabitants, with only 12 municipalities with a population above 500,000 participating in public consortia. Municipalities with a population of up to 20,000 inhabitants, small towns (ENDLICH, 2017ENDLICH, A. M. Cooperações intermunicipais: alguns aportes. Maringá: PGE-UEM, 2017.), constitute 72% of the municipalities in the health consortium.

In the State of Paraná, the PHC played a fundamental role in strengthening municipal management in all Health Regions of the state territory. Its organization is concomitant with the construction and consolidation of the SUS, and the first PHC in the state were implemented in the early 1990s, in the regions of Paranavaí and Campo Mourão. In 1998, there were already twenty health consortia in Paraná, which emerged due to the need to structure the Specialty Centers (ANTONIACONI, 2016ANTONIACONI, G. Consórcios intermunicipais de saúde e o processo de implantação do COMSUS no Estado do Paraná. Dissertação (Mestrado) - Universidade Estadual de Londrina, Londrina, 2016.).

Currently, in Paraná there are 26 PHC, representing 96.4% of the 399 municipalities in the territory, present in all 22 Health Regions. Its role went beyond the function of contracting services, acting as a strategic supporter in the implementation of public policies in the region. Of this total PHC, only one is configured in a vertical format, with the participation of the state government, with the exclusive purpose of purchasing medicines.

Collective action in evidence

CA requires, according to Melucci (1989MELUCCI, A. Um objetivo para os movimentos sociais. Rev. Lua Nova, v. 17, p. 49-66, 1989. ), the sharing of a collective identity, having in common the ability to recognize and be recognized as part of the same social unit. In a contribution, Gohn (1997GOHN, M. G. M. Teoria dos movimentos sociais: paradigmas clássicos e contemporâneos. São Paulo: Edições Loyola, 1997.) emphasizes that it is not just the sum of individualities, but a joint action, a collective project.

The concept of AC, for Melucci (1989MELUCCI, A. Um objetivo para os movimentos sociais. Rev. Lua Nova, v. 17, p. 49-66, 1989. ), is developed through the Theory of New Social Movements (TNSM), emphasizing its distinction to models that refer to these as maladjustments in the political and social order or products of crisis; or even as an expression of shared beliefs. Thus, he points out that, based on this conceptual overcoming, social aggregation is a permanent phenomenon, since it is a stable and irreversible component of contemporaneity.

For Melucci (1989MELUCCI, A. Um objetivo para os movimentos sociais. Rev. Lua Nova, v. 17, p. 49-66, 1989. ), the motivation for CA is far from the economistic approach, moving away from the previous Marxist pattern; however, subjects start to fight not only for power or goods, but imbued with a new orientation, there is a search for other immeasurable goods, such as self-fulfillment, solidarity and identity.

Highlighting the collective identity, Melucci (2001MELUCCI, A. A invenção do presente. Rio de Janeiro: Vozes, 2001.) points out that this is not a given or an essence, but a product of exchanges, negotiations, decisions and conflicts, considering the conflict to be present in everyday life, so that the individual's problems have been transformed in collective problems.

When referring to CA, Gohn (2000GOHN, M. G. M. 500 anos de lutas sociais no Brasil: movimentos sociais, ONGs e terceiro setor. Rev. Mediações, Londrina, v. 5, n. 1, p. 11-40, jan-jun. 2000.) indicates that it can manifest itself through large-scale actions or in a less visible way, through organization and communication between groups (COHEN, 2005COHEN, J. Strategy or Identity: New Theoretical Paradigms and Contemporary Social Movements. Social Research, n. 52, p. 663-716, 1985.). In this sense, Gohn (2005)GOHN, M. G. M. Cidadania e direitos culturais. Revista Katálysis, Florianópolis, v. 8, n. 1, p. 15-23, jan. 2005. emphasizes that the political dimension is a central factor in the constitutive social action of movements, forming a social collective, which assumes a common demand (GOHN, 2000GOHN, M. G. M. 500 anos de lutas sociais no Brasil: movimentos sociais, ONGs e terceiro setor. Rev. Mediações, Londrina, v. 5, n. 1, p. 11-40, jan-jun. 2000.). Finally, Melucci (2001MELUCCI, A. A invenção do presente. Rio de Janeiro: Vozes, 2001.) states that social conflicts do not disappear, nor does CA. He points out that “there will be an increase in the capacity to produce conflicts and build collective identities, more transitory and more flexible” (p. 10).

Thus, CA is configured as a motivating axis for the decision-making and change process, to which planning refers, and it should be approached from the perspective of the values ​​of solidarity, considered other equally significant aspects for health management, which namely: collective identity (which is linked to territorialization and Health Regions), the action of actors (this being a collective action), culture (represented by respect for territorial specificities in the context of health management), daily struggles (which are the practices, actions and instruments of management) and ideology (the principles of the SUS, among other common ideals, may appear as presuppositions).

The search path

This study presents an exploratory, descriptive and analytical qualitative approach, focusing on the perception of the participating subjects. The study was carried out in the Middle Paranapanema region of the North of Paraná, which includes 21 municipalities, with a total population of about one million. It is a region that has predominantly small municipalities, with only the main municipality of the region being considered large, with approximately 600 thousand inhabitants (IBGE, 2016).

The regional territory has a PHC, headed by a president elected by his peers mayors and a governing body. It has a technical council, made up of health managers and a fiscal council, made up of subjects from the public administration and social control of the consortium municipalities. The actions developed by the consortium are: a) maintenance of a Specialty Center, which performs approximately 800 thousand procedures/year; b) School of Health; c) Outpatient Regulation Unit, with regionalized assistance regulation service; d) Program to support municipal urgency and emergency; between others.

The research subjects were the managers and agents of the management team of the municipalities in the region, the consortium and the state and federal health management sphere, totaling 15 participants. It was considered as an inclusion criterion the representation of health management of municipalities of different sizes, in addition to subjects who work in the federative relationship with municipalities, representatives of state and union management. None of the municipal managers of the territory covered by the consortium were considered among the exclusion criteria; however, the absence of some of the subjects from the focus groups was considered a loss for the study.

In an analysis of the length of experience in the managerial role, it was found that: 12% of the participants had been working for less than 12 months; about 5% of participants, between 12 and 24 months; 51.5% of participants between three and four years in the function and 31.5% of participants working between six and 11 years in the function. With regard to employment, 63% of those interviewed in the study have a municipal statutory bond, about 5% have a state bond and 32% were in positions of free appointment.

As a data collection instrument, focus groups and complementary interviews were used. The focus groups were carried out separately with representatives of the health management of small municipalities, classified by population base in a group with municipalities with up to 6,000 inhabitants and another with municipalities with 6,000 to 20,000 inhabitants, considering their specificities. The interviews were carried out with subjects representing medium and large cities, with participants from other spheres of management and from the consortium. The questions that guided the data collection process dealt with the PHC practices and its role in the health regionalization process. The interviews and focus groups were recorded and transcribed in full.

For data analysis, the discourse analysis method was used, covering two moments, as proposed by Martins and Bicudo (2003MARTINS, J.; BICUDO, M. A. V. A pesquisa qualitativa em psicologia: fundamentos e recursos básicos. São Paulo: Centauro, 2003.). The first consisted of individual or ideographic analysis, based on the reading of descriptions, for the appropriation of the content of the subjects' speeches, without interpretations, enabling empathy and experimentation of their realities. Then, the units of meaning were discriminated from the speeches and these were then interpreted using linguistic instruments, making the ways of representing the data and the meaning transmitted more evident. In the second moment, a general or nomothetic analysis was carried out, which consists of the understanding and articulation of the different meanings from the re-reading of the collected material, making approximations and identifying convergences and divergences in the units of meaning, resulting in the construction of study configuration categories . With this, from 142 speech excerpts classified into 55 units of meaning, it became possible, from sharing their daily lives, reflections and listening to themselves, to unveil, in analysis of the elements of the discourse, the relevant aspects for the questions of this study, in light of the theoretical foundation of CA (MELUCCI, 1996MELUCCI, A. Challenging codes: collective action in the information age. Cambridge University Press; 1996.; GOHN, 1997GOHN, M. G. M. Teoria dos movimentos sociais: paradigmas clássicos e contemporâneos. São Paulo: Edições Loyola, 1997.).

The research is an integral part of the study “Interfederative SUS management in the organization of regional arrangements for medium complexity care in the northern macro-region of Paraná”, approved by the Research Ethics Committee of the State University of Londrina under CAAE opinion nº 56868416.1.0000.5231. All ethical and scientific requirements and foundations contained in CNN Resolution No. 466/12 (BRASIL, 2012), which regulates research with human beings, were respected and participants signed an informed consent form.

Results and discussion

The results and discussion are organized in order to unveil situations that limit and, in sequence, situations that favor collective action by the PHC with regard to the regionalization process, as systematized in table 1.

The study results indicate that in the practice of health management, especially in regional territories, conflicts of interest and difficulties in regional planning that consider the needs and specificities of the territory are highlighted, a fact that makes the regionalization process even more challenging. Collective action is a unique element for the consolidation of regionalization, serving as a strategy for expanding the vision of the needs and potential of entities, enabling the implementation of regional planning. Through CA, the feasibility of convergence of municipal health plans is built, with a focus on common goals. CA is effected through the values ​​of alterity, solidarity and collective identity between entities, and can be made possible through consortium action.

Analyzing the performance and role of public consortia, according to the perception of the subjects of this study, it was found that there are conditions that limit collective action and conditions that favor it (Table 1), pointing to paths for regional strengthening. Among the conditions that limit collective action, two situations were highlighted that do not contribute to the realization of regionalization through the PHC. The first is the confusion about the role of the consortium. The perception of the PHC as a service provider was present in the discourse of the research subjects.

This confusion with the figure of the provider occurs, in general, because the consortium has a different legal status from the federative entities, through which it is possible to optimize the provision of public services. However, insofar as the PHC is appointed as a provider, it is not treated by the municipal entity as an arrangement that produces collective action. This understanding is reinforced in the general scope of the State of Paraná, since, in that territory, consortia were born from the need to structure specialized care units, supported by the state government (ROCHA, 2016ROCHA, C. A. A cooperação federativa e a política de saúde: o caso dos Consórcios Intermunicipais de Saúde no estado do Paraná. Cad. Metrop., v. 18, n. 36, p. 377-99, 2016.).

Although decision-making within the PHC is carried out by the mayors and secretaries of Health, it appears that this identity reference delegated to the PHC through the Specialty Centers boosted the mercantilist view of the consortium with municipal managers, resulting in experiences that produced distances between these.

Another factor that contributes to this confusion is the contracting of public services carried out by the PHC, as they manage care points through program contracts. Such experiences, in a way, contributed to the construction of an ideal that relates the consortium to a provider, which is difficult to modify. However, service providers are responsible for defending their organizational and individual interests, which differs from the public consortium, since its consortium nature represents the collective interests of the consortium entities, through programs of common interest.

In addition to associating the image of the public consortium with the figure of service provider, the functions of public consortia are also confused with that of the health manager, which in Brazil is exercised by the three spheres of government: municipality, state and union. However, the PHC is not and must show a pretense of becoming a federative entity, so that the municipal entity cannot leave its protagonist role in the regional context.

Another role that can be assigned to the consortium is that of a mediator in contracting services for the integration of assistance between the different points of care, which reduces the role of the consortium and impedes its full performance. Consortia were mentioned as tools for contracting services, in the position of indirect administration of the public entity. However, this role is a limiting factor for the consortium's performance, since the mediator is limited to operational tasks, distancing himself from the objectives shared between the entities that compose them.

Given these perceptions, it is worth reflecting on how much the PHC itself, through its performance, reinforces or not the figure of manager, provider or mediator of services. The definition and transparency of the role of the consortium as an instrument to support the health management of its member entities enhance regionalization and strengthen the SUS. The path to advances in this direction requires moving away from both the individualistic behavior of a service provider and the pretension of acting as a manager and acting as a mere mediator of services. This confusion about the role of the PHC hinders the regionalization process and becomes an impediment for CA to take place through the constitution of public consortia between federative entities.

Another scenario that does not favor collective action is the relationship of different interests between the PHC and the state and federal spheres. Historically, the Brazilian federation has been characterized by strong centralism on the part of the Union, so that when the inducing policies coming from the Union are not consistent with some local realities, tensions are revealed. This is because, due to the low revenue of municipalities, especially small towns, they are tempted to adhere to policies that offer financial incentives, without, however, evaluating their contribution to the process of strengthening the Health Region. In this way, the municipality feels compelled to expand their services to obtain greater transfer (SOUZA; MELO, 2008SOUZA, M. K. B.; MELO, C. M. M. Perspectiva de enfermeiras acerca da gestão municipal de saúde. Revista de Enf. da UERJ. Rio de Janeiro, v. 16, n. 1, p. 20-5, 2008.) and subnational entities become hostages to financial induction policies (LIMA, 2008LIMA, L. D. Federalismo fiscal e financiamento descentralizado do SUS: balanço de uma década expandida. Trabalho, educação e saúde, v. 6, n. 3, p. 573-598, 2008. ).

In this same sense, the relationship of the PHC with the state sphere can also present tensions, when inducing uniform public policies through incentives, without understanding local specificities. On the other hand, the PHC are called for by their constitutive nature to act in accordance with the needs and specificities of their member entities and have historically been consolidated due to the absence of the State in fulfilling certain roles with the municipality. In addition, the non-compliance with the financial transfer by the Union and the states, in accordance with the provisions of Complementary Law No. 141/2012, has historically been one of the greatest obstacles to the decentralization process, burdening the municipal entity (PINAFO; CARVALHO; NUNES, 2016PINAFO, E., CARVALHO, B.G.; NUNES, E.F.P.A. Descentralização da gestão: caminho percorrido, nós críticos e perspectivas. Ciência & Saúde Coletiva, v. 21, n. 5, p. 1511-1524, 2016. Disponível em: <https://doi.org/10.1590/1413-81232015215.18942015>. Acesso em: 15 jul. 2020.
https://doi.org/10.1590/1413-81232015215... ).

One of the ways to strengthen the role of the State can be made possible through the Integrated Regional Planning, which, presented by CIT Resolution No. 37/2018 (BRASIL, 2018) and other instruments, establishes a set of guidelines in order to advance the process of SUS regionalization, once coordinated by the federative states for the implementation of health policies based on the diagnosis ascertained in the regional territories and carried out by the municipalities and local technical teams.

However, different interests between federative entities are part of the Brazilian democratic political regime, so that debate and conflicts are significant elements for building consensus, provided for in SUS regulations. Complementarily, the interests of the consortia must be representative of the common interests of their consortium entities. In the case of this study, since it is a horizontal consortium made up of municipalities, it is natural that municipal, state and federal interests do not converge, at least initially. In this sense, it is up to the consortia to maintain transparency about the interests they represent and to position themselves as a tool for articulation in the federative relationship. In this way, the performance of the PHC differently from the interests of its member entities discourages entities from acting collectively and distances them from the process of strengthening regionalization.

On the other hand, given the conditions that favor collective action, four aspects were found. The first significant aspect evidenced from the report of the experiences of the actors involved in the study was the representativeness of the consortium action. Municipal managers reinforce the figure of the public consortium as a representative of municipal management. In addition, they point to a scenario of approximation and free transit of information to the consortium members, emphasizing the PHC' performance with equity and its contributory involvement with public policies within the scope of RS. This result is consistent with the concept of CA insofar as the representativeness expressed by the subjects can be understood with the collective identity mentioned by Melucci (1989MELUCCI, A. Um objetivo para os movimentos sociais. Rev. Lua Nova, v. 17, p. 49-66, 1989. ).

The process of implementing federative cooperation through consortium action represented a transition in public management and the passage from a competitive standard to a horizontal and representative cooperative system. According to Rocha and Faria (2004ROCHA, C. V.; FARIA, C. A. P. Cooperação intermunicipal, reterritorialização da gestão pública e provisão de bens e serviços sociais no Brasil contemporâneo: a experiência dos Consórcios de Saúde de Minas Gerais. Cadernos Metrópole, v. 11, n. 1, p. 73-105, 2004.), this is a process of "defragmenting public management", so that when municipalities act together, they obtain several positive results, such as: a) increased capacity for achievement with expansion the reach of public policies; b) greater efficiency in the use of public resources; and c) carrying out actions that would be inaccessible to a single city hall. Thus, cooperation can be a way of joining efforts to meet the individual needs of municipalities in terms of financial, technological and human resources, necessary to carry out their duties.

Another indication that favors the construction of collective action is the recognition, by municipal managers, subjects of the study, of the nature of collaboration that the consortium promotes, since its action reduces the individual costs of municipalities in the implementation of health actions, in addition to working on the solution of care problems in RS. The collaborative character is one of the great structuring axes of collective action. Therefore, when the participants recognize its collaborative aspect in the role of the PHC, the relationship between this result and the framework under analysis becomes evident.

The collaborative character of the PHC has become fundamental in the context of some Brazilian locations, since the municipalization initiatives took place without the care of linking these new responsibilities with financial resources, economic and social development (ARAUJO, 2006ARAUJO, T. B. Desenvolvimento regional: a descentralização valorizaria a diversidade. In: FLEURY, S. (org.) Democracia, descentralização e desenvolvimento: Brasil & Espanha. Rio de Janeiro: FGV; 2006. p. 373-96.), being reinforced in this place of study.

An important characteristic when analyzing the Brazilian context and which coincides with the studied location is the fact that most municipalities are of low population size, without consistent economic activity for fiscal and tax self-sufficiency and with low technical capacity in municipal management. In addition, these are more dependent on constitutional transfers, have a low capacity for their own collection and high expenses with the funding of the executive and the legislature (LEITE, 2014LEITE, F. L. B. Fusão de municípios: impactos econômicos e políticos da diminuição do número de municípios em Minas Gerais. Dissertação (Mestrado) - Universidade do Minho, Portugal, 2014. ).

Given these limitations, these municipalities are unable to offer their citizens health actions and services in a satisfactory manner. This makes arrangements that favor inter-municipal cooperation strategic when it comes to distant locations with low population density. This is what the study by Nicoletto, Cordoni Júnior and Costa (2005NICOLETTO, S. C. S.; CORDONI JR, L.; COSTA, N. R. Consórcios Intermunicipais de Saúde: o caso do Paraná, Brasil. Cad Saúde Pública. Rio de Janeiro, v. 21, p. 29-38, 2005. ), developed in the northern region of Paraná, pointed out, whose municipalities with less than 10 thousand inhabitants were the ones that most adhered to the consortia.

In defense of arrangements based on inter-municipal cooperation, Endlich (2017ENDLICH, A. M. Cooperações intermunicipais: alguns aportes. Maringá: PGE-UEM, 2017.) states that “a competitive world scenario cannot produce anything other than an even more unstable geography with social conditions increasingly marked by social inequality”. In this sense, another study corroborates the reflection on cooperation arrangements, also indicating the role of the PHC in its cooperative role, as an "organizational arrangement in the role of articulator of the performance of the municipal manager" (MENDONÇA; ANDRADE, 2018MENDONÇA, F. F.; ANDRADE, S. K. A. V. Consórcio Público de Saúde como arranjo para relação federativa e o processo de regionalização. Redes. Santa Cruz do Sul, v. 23, n. 3, p. 206-224, set. 2018. , p 220). Therefore, the need to recognize and build cooperative processes as strategic for overcoming social problems in the regions and for the role of the public consortium in its collaborative nature is reinforced.

Furthermore, the subjects emphasize that, due to the discontinuity in management and the reduced number of professionals working in the management team in small municipalities, the collaborative nature of the PHC allows not only greater access to health care, but also support in organization of management strategies and articulation among peers for joint planning and construction of viable alternatives in the regional territory.

Consortia are also identified as fundamental in the development of permanent and continuing education processes, whether with management teams or assistance teams. The subjects report that, after the initiative of the consortium in the region, the municipalities became demanding training strategies for the Primary Care teams, with a view to problematizing and technically preparing the daily functions, such as: case studies, implementation of clinical regulation protocols, updates in resolving clinical management in health, appropriate use of technologies, exchanges between different professionals and areas of expertise, among others.

With this, the municipal managers, subjects of the study, emphasize that the permanent and continuing education activities carried out by the Health School of the public consortium in the region have favored the qualification of the demand for specialized care services, with a view to resolving this level of care. . As mentioned, the study region has, above all, small municipalities, which have some limitations with regard to technical issues. Therefore, training and qualification processes for these teams are fundamental and represent a process of solidarity, one of the elements of collective action, making the SR more powerful to act in the structuring of a network of services that meets regional interests.

Corroborating these results, Rivera (2016RIVERA, R. H. A. Las mancomunidades y consorcios públicos como mecanismos de gestión de los gobiernos autónomos descentralizados en el Ecuador. Tesis (Maestria) - Quito: Universidad Andina Simón Bolívar, Sede Ecuador, 2016.) states that through consortium initiatives, it is possible to manage services in conditions of efficiency, effectiveness and quality, promoting economic development and wealth distribution.

Analyzing another aspect, the consortium is cited as an agent for raising public resources, for investment purposes in the regional territory, as pointed out by the study subjects. The subjects point out that the executive directors of the consortium play a role in raising funds from the Union and the State, through the presentation of solution projects for the needs of the Health Region.

The same was pointed out by Teixeira (2017)TEIXEIRA, L. S. Ensaios sobre consórcios intermunicipais de saúde: financiamento, comportamento estratégico, incentivos e economia política. Brasília: CODEP, 2007 (Temas de interesse do legislativo, 11)., who mentions that the joint action favors the application of incentives from the state and federal government, so that these will support the acquisition of new technologies or implementation of services through the public consortium.

The initiatives identified are in line with what collective action points out and confirm that the resulting benefit, when carried out through the consortium, impacts the empowerment of entities in the relationship between peers and with other spheres of management, promoting scenarios of cooperation and solidarity.

From the representativeness of the consortium action, its collaborative character, the promotion of permanent and continuing education strategies in health with the consortium entities and, finally, the support for raising public resources for the feasibility of implementing regional projects, in short, all these aspects mentioned above favor collective action and are factors that encourage regionalization, in a powerful process for its consolidation.

Final considerations

The perception of managers about the PHC at the study site presents conditions that limit and favor collective action, pointing to possible paths for strengthening and benefiting the regionalization process. The conditions that limited CA were: a) confusion about the role of the PHC, with an understanding of this role as a service provider, manager or mediator of services; and b) the relationship of different interests between the PHC and the state and federal government.

The conditions that favor collective action and show that the consortium has acted in a manner consistent with this concept: a) the representativeness that the PHC promotes with the collective of municipalities; b) the collaborative character of the PHC; c) the development of permanent and continuing education actions; and d) the capture of public resources benefiting the regional territory.

In view of this scenario, it appears that despite being provided for in a legal and normative way since the beginning of federalism, the consortium arrangements face limitations for their performance. However, if used properly, they can promote the strengthening of health regions and, consequently, the regionalization process.

However, it is necessary to reduce the unfavorable conditions for CA through measures to structure institutional instruments that favor cooperation and clarify the role of consortia and transparency in the positioning between entities, for the construction of partnerships based on trust, cooperation and regional planning, considering the needs of the territories. These initiatives through the PHC can be developed through the gathering of actors who interact as protagonists, through a mediation network for the empowerment of managers and the health region, which enables the consolidation of Regionalization.

Finally, the study shows the importance of the PHC for regionalization, being an associative tool for federative cooperation, an instrument that should be encouraged and strengthened. For its potentialization, it is necessary that the public consortium is not only understood as an entity provided with its own legal nature, a tangential institution or a new instance of articulation, but that it is considered as support in the spaces of dialogue and decision and increasingly taken as an instrument for exercising collective action.²2SKAV Andrade participated in the design, data interpretation, article writing and text review. FF Mendonça, AM Endlich and AD González participated in the analysis, article writing and text review.

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