Abstract

This study analyzes the dissolution of the institutional cooperation, lasting approximately a decade, between the Ministry of Health and a set of academic institutions for the implementation of the National Program for Improving Access and Quality of Primary Care (PMAQ-AB) in the scope of the Brazilian Nacional Health System (SUS). This exploratory, qualitative research consists of a case study that uses assumptions of Historical Neoinstitutionalism to guide the analysis. Data were collected by documentary and bibliographic research and semi-structured interviews with key actors. From the content analysis, three analytical categories were evidenced: end of the PMAQ-AB - historical process, political-institutional context and actors; end of the institutional cooperation - government-academy interaction process; and actors’ perceptions about the end of institutional cooperation. The end of institutional cooperation happened in a context of change of government at the federal level, within a new political-institutional order of SUS and was influenced by historical factors and the practices of public managers and in the conduct of political processes. An inter-institutional government-academy exchange with a view to strengthening health management and supporting the institutional development of the SUS is a future expectation, considering the adversities imposed on the field of health and public education in Brazil today.

Keywords:
Public Health; Primary Health Care; Academic institutions; Intersectoral Collaboration

Introduction

The New Public Governance paradigm, especially since the 2000s, has influenced public managers to offer higher quality services to citizens (Pereira et al., 2017PEREIRA, F. N. et al. Nova gestão pública e nova governança pública: uma análise conceitual comparativa. Espacios, Caracas, v. 38, n. 7, p. 6-26, 2017.). In the health field, there is an increase in policy-making processes through formal articulation with academic institutions, with the perspective of implementing innovative programs to obtain better results in the Unified Health System (SUS). This stems from the complexity of integrating scientific knowledge with public health policies from the perspective of Evidence-Informed Policy (PIE) (Ramos; Silva, 2018RAMOS, M. C.; SILVA, E. N. Como usar a abordagem da política informada por evidência na saúde pública?. Saúde em Debate, Rio de Janeiro, v. 42, n. 116, p. 296-306, 2018.).

In Primary Care (PC), in the last two decades, the Ministry of Health (MS) has become closer to Teaching and Research Institutions (IEPs) (Facchini; Tomasi; Thumé, 2021FACCHINI, L. A.; TOMASI, E.; THUMÉ, E. (Org.). Acesso e qualidade na atenção básica brasileira: análise comparativa dos três ciclos da avaliação externa do PMAQ-AB, 2012-2018. São Leopoldo: Oikos, 2021.; Primary Health Care Research Network, 2018). In this context, in 2011, MS engaged in institutional cooperation with Brazilian PEIs as part of the political-institutional initiatives to implement the Program for Improving Primary Care Access and Quality (PMAQ-AB). The program aims to induce changes in health management and care, to improve access to services and raise the quality of care offered to citizens. To this end, the transfer of federal funds to the municipalities was tied to the performance achieved in the nationally predefined evaluation processes (Cavalcanti; Fernandez; Gurgel Junior, 2021CAVALCANTI, P.; FERNANDEZ, M.; GURGEL JUNIOR, G. D. Cooperação entre academia e governo para avaliar a APS no SUS. Interface, Botucatu, v. 25, n. e210103, 2021. DOI: https://doi.org/10.1590/interface.210103
https://doi.org/https://doi.org/10.1590/... ).

According to Cavalcanti, Fernandez and Gurgel Junior (2021CAVALCANTI, P.; FERNANDEZ, M.; GURGEL JUNIOR, G. D. Cooperação entre academia e governo para avaliar a APS no SUS. Interface, Botucatu, v. 25, n. e210103, 2021. DOI: https://doi.org/10.1590/interface.210103
https://doi.org/https://doi.org/10.1590/... ), this cooperation provided the formulation and operationalization of the external evaluation of PMAQ-AB, as well as the development of management support and academic activities, considering the IEPs’ knowledge about the SUS and PC, and their expertise in evaluative research. It has also provided a greater degree of impartiality, legitimacy, and credibility to the evaluation process of the program, mainly due to the pay for performance. However, in 2019, the PMAQ-AB and, consequently, the government-academy cooperation were terminated.

Currently, there are no scientific studies that explore historical circumstances, with emphasis on political-institutional events that can lead to discontinuity in policies (Nogueira, 2006NOGUEIRA, F. A. Continuidade e descontinuidade administrativa em governos locais: fatores que sustentam a ação pública ao longo dos anos. Dissertação (Mestrado em Administração Pública e Governo) - Fundação Getúlio Vargas, São Paulo, 2006.), and their effects on this cooperation. Thus, the purpose of this article is to contribute to a better understanding of the dissolution of this institutional cooperation, which lasted for about a decade and spanned several MS administrations, between the country’s health authority and a set of IEPs for the implementation of PMAQ-AB. The perspectives of the institutional actors of SUS who have expressed opinions about the end of this partnership will also be considered.

Historical Neoinstitutionalism as a reference to analyze the end of government-academy cooperation in PMAQ-AB

Historical Neo-institutionalism (HN) considers the role of institutions in shaping actors’ actions and sustaining policies, while valuing other conditioning aspects of policy formulation and implementation processes, such as actors, their interests, and strategic actions (Immergut, 1998IMMERGUT, E. M. The Theoretical Core of the New Institutionalism. Politics and Society, Thousand Oaks, v. 26, n. 1, p. 5-34, 1998.); socioeconomic developments; and ideas (Hall; Taylor, 2003HALL, P. A.; TAYLOR, R. C. R. As três versões do neo-institucionalismo. Lua Nova , São Paulo, n. 58, p. 193-223, 2003.). Institutions comprise the formal and informal rules inherent in the organizational structure of the political community, which mediate relations between actors. In this sense, they provide actors with moral and cognitive models that enable interpretation and action, while influencing their preferences, identities, and goals (Hall; Taylor, 2003HALL, P. A.; TAYLOR, R. C. R. As três versões do neo-institucionalismo. Lua Nova , São Paulo, n. 58, p. 193-223, 2003.; Pierson, 2000PIERSON, P. Increasing returns, path dependence, and the study of Politics. The American Political Science Review, Cambridge, v. 94, n. 2, p. 251-267, 2000.).

According to North (2018NORTH, D. C. Instituições, mudança institucional e desempenho econômico. São Paulo: Três Estrelas, 2018.), the outcomes of public policy are contingent and dependent on the struggle and strategies outlined by various actors, in the social and political space in which they interact. In the political dispute arena, decisions originate in political and social processes influenced by institutional factors and the often conflicting interests, worldviews, and ideas of the actors (Immergut, 1998IMMERGUT, E. M. The Theoretical Core of the New Institutionalism. Politics and Society, Thousand Oaks, v. 26, n. 1, p. 5-34, 1998.). Thus, the combination of processes undertaken by institutions and actors with decision-making power is capable of directing the strategies adopted within the scope of public policies, which determines path dependency (Pierson, 2000PIERSON, P. Increasing returns, path dependence, and the study of Politics. The American Political Science Review, Cambridge, v. 94, n. 2, p. 251-267, 2000.).

One understanding of the term explains that the choices made at a given historical moment condition later choices, while constraining many others (Immergut, 1998IMMERGUT, E. M. The Theoretical Core of the New Institutionalism. Politics and Society, Thousand Oaks, v. 26, n. 1, p. 5-34, 1998.; Pierson, 2000PIERSON, P. Increasing returns, path dependence, and the study of Politics. The American Political Science Review, Cambridge, v. 94, n. 2, p. 251-267, 2000.). That is, past choices exert a constraining effect on the future through the continuity of a society’s institutions (North, 2018NORTH, D. C. Instituições, mudança institucional e desempenho econômico. São Paulo: Três Estrelas, 2018.). This premise points to an inertial trend in institutions. Once a path is adopted, the political and economic costs of changing it are usually high (Immergut, 1998IMMERGUT, E. M. The Theoretical Core of the New Institutionalism. Politics and Society, Thousand Oaks, v. 26, n. 1, p. 5-34, 1998.; Pierson, 2000PIERSON, P. Increasing returns, path dependence, and the study of Politics. The American Political Science Review, Cambridge, v. 94, n. 2, p. 251-267, 2000.). However, it is admitted that the trajectory of institutions and public policies is also marked by historical sequences and contingencies, in which elements capable of provoking variations and ruptures are present, in terms of trajectory or subsequent results (Pierson, 2000PIERSON, P. Increasing returns, path dependence, and the study of Politics. The American Political Science Review, Cambridge, v. 94, n. 2, p. 251-267, 2000.).

The change in trajectory can be interpreted as an effect of exogenous factors, related to the structure of institutions and the institutional environment, which cause a rupture in historically verified and reinforced action patterns, characterizing a critical moment or a critical juncture (Pierson, 2000PIERSON, P. Increasing returns, path dependence, and the study of Politics. The American Political Science Review, Cambridge, v. 94, n. 2, p. 251-267, 2000.). These are situations of political or economic transition that enable the reconfiguration of political processes and the exchange of institutions for new ones, which, in turn, favor changes in politics (March; Olsen, 2008MARCH, J. G.; OLSEN, J. P. Neo-institucionalismo: fatores organizacionais na vida política. Revista Sociologia Política, Curitiba, v. 16, n. 31, p. 121-142, 2008. DOI: 10.1590/S0104-44782008000200010
https://doi.org/10.1590/S0104-4478200800... ). Another sense is based on incremental change, whose explanatory aspects of intra-institutional dynamics, especially related to the action of actors, can induce significant transformations in the policy trajectory (Mahoney; Thelen, 2010MAHONEY, J.; THELEN, K. A theory of gradual institutional change. In: Explaining institutional change: ambiguity, agency, and power. Cambridge: Cambridge University Press, v. 1, p. 1-37, 2010.).

Institutions matter from the perspective of changing or maintaining the status quo and must be analyzed in association with historical facts, in a longitudinal sequence. History matters, as knowledge about it can elucidate how events connect and relate to each other while determining the course of politics (Hall; Taylor, 2003HALL, P. A.; TAYLOR, R. C. R. As três versões do neo-institucionalismo. Lua Nova , São Paulo, n. 58, p. 193-223, 2003.; Pierson, 2000PIERSON, P. Increasing returns, path dependence, and the study of Politics. The American Political Science Review, Cambridge, v. 94, n. 2, p. 251-267, 2000.). Therefore, in this article, the historical-institutional approach is useful to investigate factors that had repercussions on the trajectory of dependence of institutional cooperation between MS and IEPs, established from the PMAQ-AB, through the political-institutional characteristics of the time, considering the role of institutions and actors in the formulation, decision and implementation of public policies.

Methodology

This exploratory, qualitative research consists of a case study that uses assumptions from NH as a model for policy analysis. Given its complexity, we sought to combine methods and data collection sources, aiming to obtain information from different angles or points of view, to develop convergent lines of investigation and enable a triangulation process. This strategy limits personal and methodological biases, contributing to the validity of the research (Minayo, 2014MINAYO, M. C. D. S. O desafio do conhecimento: pesquisa qualitativa em saúde. 14. ed. São Paulo: Hucitec , 2014.).

Initially, the analyses on PMAQ-AB showed that several aspects related to the participation of IEPs in the cooperation, from the selection criteria to the factors that led to the suspension of the cooperation, were not explained by MS in official documents. To achieve a better understanding of the political-institutional context of the Federal Government, a complementary documentary and bibliographic research was conducted.

This study used scientific articles found in the databases of the Virtual Health Library (BVS), the Scientific Electronic Library Online, and the Periodicals Portal of the Coordination for the Improvement of Higher Education Personnel (Capes). The search was conducted by the terms “PMAQ-AB”, “Avaliação Externa”, “Programa Previne Brasil” (substitute to PMAQ-AB). Furthermore, we used publications of various natures (interviews, reports, news, articles, and texts), published in the media and by entities in the field of public/collective health.

The methodological option for allocating individuals in the research sought to ensure adequacy to the predefined purpose. Therefore, it was not based on numerical representation per se, but considered obtaining satisfactory elements to deepen the knowledge about this cooperation, aiming to enable profitable interpretations and inferences, ensuring a sufficient number of participants, considering the saturation point (Minayo, 2014MINAYO, M. C. D. S. O desafio do conhecimento: pesquisa qualitativa em saúde. 14. ed. São Paulo: Hucitec , 2014.). Therefore, the interviews focused on key actors, who certainly have fundamental information about the context and the social and political-institutional dynamics related to the object of study, due to their institutional involvement in the process of implementation of PMAQ-AB via government-academy cooperation.

As a selection criterion, MS representatives who held a management position in the area of primary care between 2011 and 2019 were sought. Researchers and representatives of the “main” IEPs participating in the National Coordination of External Evaluation (the national space for cooperation interaction) were also sought. The “main” IEPs are of interest because of the institutional involvement in the initial negotiations for the effectiveness of the cooperation under the PMAQ-AB. They received financial resources and led the operational processes for the execution of PMAQ-AB, while some formed consortiums with similar institutions (Cavalcanti; Fernandez; Gurgel Junior, 2021CAVALCANTI, P.; FERNANDEZ, M.; GURGEL JUNIOR, G. D. Cooperação entre academia e governo para avaliar a APS no SUS. Interface, Botucatu, v. 25, n. e210103, 2021. DOI: https://doi.org/10.1590/interface.210103
https://doi.org/https://doi.org/10.1590/... ; Facchini; Tomasi; Thumé, 2021FACCHINI, L. A.; TOMASI, E.; THUMÉ, E. (Org.). Acesso e qualidade na atenção básica brasileira: análise comparativa dos três ciclos da avaliação externa do PMAQ-AB, 2012-2018. São Leopoldo: Oikos, 2021.). The study also included representatives from the National Council of Health Secretaries (Conass) and the National Council of Municipal Health Secretaries (Conasems).

Representatives of IEPs from partner institutions who did not participate in the initial negotiations for this cooperation were not considered. Local representatives from states and municipalities were not invited either. Although it is recognized that in the SUS governance space, in the Tripartite Interagency Commission in which negotiations about national health public policies take place, there is an imbalance of power among the federated entities and gaps in institutional representation (Pires, 2019PIRES, R. R. C. (Org.). Implementando desigualdades: reprodução de desigualdades na implementação de políticas públicas. Rio de Janeiro: Ipea, 2019.).

Subjects were invited to participate in the survey by e-mail. The semi-structured interviews, conducted using a specific script for each interviewee profile, took place from March 6 to July 30, 2020, remotely. Thus, it was possible to conduct nine interviews with the key players: three with MS leaders, four with researchers from IEPs, one with a representative from Conass, and one with a representative from Conasems.

Among the interviewees, the managers had at least a master’s degree and nine years of experience in SUS management. The researchers had at least a PhD degree and academic experience with varied publications on SUS and AB. The Conass and Conasems representatives had at least a master’s degree and more than eight years of experience in their respective entities. The anonymity of the interviewees was guaranteed using the term “G”, representing the national SUS managers, and “IEP”, for the representatives of the academic institutions, plus an Arabic numeral, arranged from one to nine.

The data approach was based on the content analysis proposed by Bardin (2015BARDIN, L. Análise de conteúdo. São Paulo: Edições 70, 2015.). The pre-analysis comprised the organization of the obtained materials with the purpose of operationalizing and systematizing the preliminary ideas. The floating reading of the collected documents allowed an understanding of the content that helped in the choice of documents to be submitted to the analysis, and in the elaboration of indicators to support the final interpretation.

In the material exploration stage, we sought to reveal characteristics of the content by identifying analytical categories, defined in the light of the NH precepts. The formulation of the analysis categories also emerged from the research corpus, to contemplate all the themes evidenced in the documents and interviews. The final categories defined in the study are: end of the PMAQ-AB - historical process, political-institutional context, and actors; end of the institutional cooperation - government-academy interaction process; actors’ perceptions about the end of the institutional cooperation. The last step was based on the evidence found to perform a content interpretation and respective understanding of the meanings.

Results

End of PMAQ-AB: historical process, political-institutional context and actors

“The end of institutional cooperation was a consequence of the termination of PMAQ-AB [...]” (G-4). This statement highlights the interrelationship of these processes. For a better understanding, we will highlight political-institutional and technical aspects that influenced the decision-making processes about the PMAQ-AB, in the spaces of political interaction and negotiation in the national sphere of SUS management. These factors had repercussions on cooperation, given the importance of external evaluation and pay for performance for the implementation of the program nationally.

According to the evidence, historically, the PMAQ-AB was initiated in the government of Dilma Rousseff (2011-2016), in the context of the revision of the National Policy for Primary Care (PNAB), in 2011, with expansion of funding for the area. The political option of MS leaders was to sign cooperation with IEPs, starting with the support of the Primary Health Care Research Network (Rede APS), from the perspective of producing knowledge and information to support decision making and formulation of health policies (Rede de Pesquisa em Atenção Primária à Saúde, 2012REDE DE PESQUISA EM ATENÇÃO PRIMÁRIA À SAÚDE. Seminário Anual da Rede de Pesquisa em APS. Brasília: Rede APS , 2012. Disponível em: <Disponível em: http://www.rededepesquisaaps.org.br/wp-content/uploads/2012/07/Relat%C3%B3rio-Rede-APS-17-de-abril-final.pdf >. Acesso em: 23 nov. 2021.
http://www.rededepesquisaaps.org.br/wp-c... ).

During the implementation of PMAQ-AB, important political-institutional changes in the Federal Government impacted MS policies. Documentary evidence shows that in 2016 there was a “climate of vagueness and slowness” in terms of the continuity of external evaluation, resulting from the “institutional crisis” observed in the Federal Government (Silva, 2016SILVA, I. Bomba: PMAQ corre risco de descontinuidade. Blog Ivando Agente de Saúde, [s.l.], 8 jul. 2016. Disponível em: <Disponível em: http://ivandoagentedesaude.blogspot.com/2016/07/bomba-pmaq-corre-risco-de.html >. Acesso em: 29 mar. 2022.
http://ivandoagentedesaude.blogspot.com/... ). After the impeachment of President Dilma, in Michel Temer’s administration (2016-2018), the PNAB underwent a new revision in 2017. Despite this, the PMAQ-AB was continued. In 2018, the APS Network (2018) stated that PMAQ-AB and performance-based incentives were at risk of discontinuity in SUS due to financial constraints arising from Constitutional Amendment No. 95 (EC 95) of December 15, 2016.

However, only in 2019, under the Jair Bolsonaro government, the PMAQ-AB was replaced by another program and, at that time, the government-academy cooperation was terminated. There was an important institutional change in MS and in health policy, especially in financing. The following statement reinforces the shortage of financial resources for health care as a reason for the end of the PMAQ-AB, as well as ideological divergence of a party-political nature.

Documents and interviews highlight two main interconnected reasons for the end of the cooperation. One of them is related to the institutional change in MS in 2019, when there was an ascension of actors opposed to PMAQ-AB to high-level institutional positions in the hierarchy, especially in the management of the Department of Primary Health Care (DAB/MS), a sector later called the Secretariat of Primary Health Care (SAPS/MS). Associated with this is the conflict of groups: 2011 ministerial leaders and 2019 ministerial leaders. The basis of the dispute is based on the dissonance of conceptions concerning public health policy and epistemological understanding about evaluation, its procedures and methods. These factors were determinant for the interruption of the program and have express correspondence with the cooperation.

According to the Escola Politécnica De Saúde Joaquim Venâncio, of the Oswaldo Cruz Foundation (EPSJV/Fiocruz) (Antunes, 2019ANTUNES, A. Proposta de carteira de serviços da atenção primária divide opiniões. Escola politécnica de saúde Joaquim Venâncio/fundação Oswaldo Cruz (EPSJV/Fiocruz), Rio de Janeiro, 30 ago. 2019. Disponível em: <Disponível em: https://www.epsjv.fiocruz.br/noticias/reportagem/proposta-de-carteira-de-servicos-da-atencao-primaria-divide-opinioes >. Acesso em: 29 mar. 2022.
https://www.epsjv.fiocruz.br/noticias/re... ), and deponents IEP-3, G-1, G-2, and G-3, the PMAQ-AB formulation process in 2011 was historically marked by controversies regarding its fundamental elements. On one hand, MS proposed the PMAQ-AB and the use of its own evaluation instrument, based on the Primary Care Assessment Tool (PCATool) and other tools. On the other hand, some researchers and members of the APS Network and the Brazilian Society of Medicine Family and Community (SBMFC) were against the initiative. They advocated the use of PCATool as an evaluative instrument, validated with support from Professor Erno Harzheim of the Federal University of Rio Grande do Sul, who held the head of SAPS/MS (2019-2020), and members of the SBMFC. The entity also suggested differentiated payment for family and community doctors (G-3). These proposals were not accepted by the MS managers at the time. Thus, the proponents refused to participate in the construction of the PMAQ-AB and the external evaluation, becoming opponents and critics of the program.

The following reports evidence that, by means of the new institutional conjuncture this dispute, which occurred during the initial negotiations of PMAQ-AB, contributed to sharpening the processes of rupture in 2019 between MS and IEPs, which formally supported the initiative.

Analyzed materials present justifications announced by MS officials for PMAQ-AB replacement. The main aspects refer to the evaluation methodology, the external evaluation instrument and its limitations, the periodicity of the evaluations, the selected monitoring indicators, the adherence criteria of the teams (including voluntary participation in the program), the dependence on contracts with universities, and the questioning of managers about the evaluation results (Harzheim, 2020HARZHEIM, E. Previne Brasil: bases da Reforma da APS. Ciência & Saúde Coletiva, Rio de Janeiro, v. 25, n. 4, p. 189-1196, 2020. DOI: 10.1590/1413-81232020254.01552020
https://doi.org/10.1590/1413-81232020254... ; Sellera et al., 2020SELLERA, P. E. G. et al. Monitoramento e avaliação dos atributos da Atenção Primária à Saúde em nível nacional: novos desafios. Ciência & Saúde Coletiva , Rio de Janeiro, v. 25, n. 4, p. 1401-1412, 2020. DOI: 10.1590/1413-81232020254.36942019.
https://doi.org/10.1590/1413-81232020254... ; Roda de Conhecimento, 2019RODA DE CONHECIMENTO: financiamento da atenção primária à saúde. [s.l.], 2019, 1 vídeo (26 min). Publicado pelo canal Tv Portal Cnm. Disponível em: <Disponível em: https://www.youtube.com/watch?v=dIVjlQPUsp0&ab_channel=TVPortalCNM >. Acesso em: 20 mar. 2022.
https://www.youtube.com/watch?v=dIVjlQPU... ).

Excerpts from the interviews emphasize problems associated with the work of academic institutions regarding the execution of the evaluation by IEPs in states other than their place of origin, as well as doubts of managers about the interviewers’ capacity and attitude. On the subject, Conasems (2020)CONASEMS - CONSELHO NACIONAL DE SECRETÁRIOS MUNICIPAIS DE SAÚDE. Nota informativa componente desempenho financiamento federal para atenção básica dos municípios. Brasília, DF, out. 2020. Disponível em: <Disponível em: https://www.conasems.org.br/wpcontent/uploads/2020/10/NOTA_INFORMATIVA_DESEMPENHO_revisao.pdf >. Acesso em: 29 mar. 2022.
https://www.conasems.org.br/wpcontent/up... explained that:

Thus, there was no request from the national representations of the states and municipalities to suspend the program and institutional cooperation. At each cycle of the program, MS, Conass, and Conasems worked together, aiming to qualify the methods employed in the evaluation process (G-1, G-3, G-4, and G-5). However, technical-political aspects favored the tripartite agreement for the replacement of PMAQ-AB.

Also in 2019, MS proposed the PPB, which constitutes the new federal funding model for AB. Replacing PMAQ-AB, the payment by performance component was included and PCATool was defined as an evaluative tool (Brasil, 2020BRASIL. Secretaria de Atenção Primária à Saúde. Departamento de Saúde da Família. Manual do instrumento de avaliação da atenção primária à saúde: primary care assessment tool (PCATooL - Brasil). Brasília, DF: Ministério da Saúde, 2020.).

Although there are criticisms of the negotiation process around PPB, such as the absence of broader debates and the disregard for the opinion of researchers, entities in the health field, and the National Health Council (CNS), in addition to arguments about the risk of reducing financial resources for municipalities (Neves; Machado, 2019NEVES, J; MACHADO, K. Atenção primária à saúde terá novo modelo de financiamento. Escola politécnica de saúde Joaquim Venâncio/fundação Oswaldo Cruz (EPSJV/Fiocruz), Rio de Janeiro:, 1 nov. 2019. Disponível em: <Disponível em: http://www.epsjv.fiocruz.br/noticias/reportagem/atencao-primaria-a-saude-tera-novo-modelo-de-financiamento >. Acesso em: 29 mar. 2022.
http://www.epsjv.fiocruz.br/noticias/rep... ; Rede de Pesquisa em Atenção Primária à Saúde, 2019REDE DE PESQUISA EM ATENÇÃO PRIMÁRIA À SAÚDE. Contribuição dos pesquisadores da Rede APS ao debate sobre as recentes mudanças na política de atenção primária propostas pelo MS. Brasília: Rede APS, 2019.), the program was pactuated at the Tripartite Interagency Commission (CIT) in 2019.

End of institutional cooperation: government-academy interaction process

The interviews revealed that the termination of the cooperation was decided by the MS management, through a process marked by the absence of debate. There was no formal communication or meeting invitation from the ministerial authorities to the IEPs to inform about the end of PMAQ-AB and the decision to terminate the partnership.

The following statement emphasizes the lack of dialogue between national managers and IEPs in conducting this process of concluding institutional cooperation.

As stated by the interviewees, there was a movement of leaders of the IEPs seeking dialogue with the ministerial authorities. The purpose was to try and maintain the government-academy rapprochement in order to elaborate evaluative strategies for AB.

According to the narratives, in an informal meeting between the cooperating institutions, MS representatives stated that the proposal was to replace the cooperation model with IEPs by a cooperation between the Brazilian Institute of Geography and Statistics (IBGE) and the Organization for Economic Cooperation and Development (OECD) to conduct evaluative research on AB in the country. After that, there was no opening for dialogue about the partnership.

The following statement corroborates the previous interview excerpt:

Analyzed documents (Brasil, 2019BRASIL. Secretaria de Atenção Primária à Saúde. Ministério terá retrato da saúde da população. Ministério da Saúde, Brasília, DF, 09 dez. 2019. Disponível em: <Disponível em: https://aps.saude.gov.br/noticia/6575 > Acesso em: 23 fev. 2022.
https://aps.saude.gov.br/noticia/6575... ; Harzheim, 2020HARZHEIM, E. Previne Brasil: bases da Reforma da APS. Ciência & Saúde Coletiva, Rio de Janeiro, v. 25, n. 4, p. 189-1196, 2020. DOI: 10.1590/1413-81232020254.01552020
https://doi.org/10.1590/1413-81232020254... ) also describe the strategies of the ministerial authorities: to perform the historical rescue of IBGE as the major external evaluator of public health policies in Brazil. From the formalization of the technical cooperation term, with the application of permanent resources, aiming to expand the component of AB in the demographic-based surveys that already exist in the country, besides establishing an unprecedented agreement with the OECD to carry out two major national evaluations in SUS, to be conducted by researchers linked to the international institution.

Managers and scholars argued that, in this context, no alternative was offered by the MS to continue with the institutional cooperation.

The interviewees mentioned that it remained for the IEPs to complete the administrative formalities related to PMAQ-AB, in order to receive the remaining financial resources. “Some IEPs had not received all the resources linked to PMAQ-AB and the qualitative study [...]. After submission of the reports, the funds were released.” (IEP-2).

Actors’ perceptions on the termination of institutional cooperation

The MS decision to suspend the cooperation was seen as a loss for SUS, with reflexes on health management and academic activities in health. The testimonies indicate that this measure characterizes an initiative to weaken democratic institutions and dismantle public policies, in the context of the current Federal Government.

The following statements assert that the termination of the cooperation dismantles and weakens the established relationships between government and academy in SUS.

The end of the cooperation was also interpreted as a modification in the government-academy interaction model, focused on the needs observed by MS.

According to the interviewees, the end of the cooperation weakens the research agenda in AB. This has negative repercussions for the development of scientific knowledge aimed at improving this area of SUS.

The end of the cooperation is reflected in the loss of data from the external evaluation, which generated important information for thinking about public health policy and subsidizing the decision making of managers at the federal level, based on the integration between science and policy in the sense of IEP.

The concern of the interviewees with the end of this government-academy approach was also observed, as its impact on public health policies, in face of the current challenges of SUS.

Discussion

This research shows the importance of the political-institutional context and actors in the closure process of government-academy institutional cooperation in PMAQ-AB, as explained by NH (Hall; Taylor, 2003HALL, P. A.; TAYLOR, R. C. R. As três versões do neo-institucionalismo. Lua Nova , São Paulo, n. 58, p. 193-223, 2003.; Pierson, 2000PIERSON, P. Increasing returns, path dependence, and the study of Politics. The American Political Science Review, Cambridge, v. 94, n. 2, p. 251-267, 2000.; Mahoney; Thelen, 2010MAHONEY, J.; THELEN, K. A theory of gradual institutional change. In: Explaining institutional change: ambiguity, agency, and power. Cambridge: Cambridge University Press, v. 1, p. 1-37, 2010.; March; Olsen, 2008MARCH, J. G.; OLSEN, J. P. Neo-institucionalismo: fatores organizacionais na vida política. Revista Sociologia Política, Curitiba, v. 16, n. 31, p. 121-142, 2008. DOI: 10.1590/S0104-44782008000200010
https://doi.org/10.1590/S0104-4478200800... ). The historical trajectory of this cooperation has been dependent on previous initiatives of approximation between government and academy in SUS, intensified during the PT governments at the federal level in the 2000s. The end of the partnership involves the rupture of the dependency trajectory, when it is possible to identify the causal mechanisms correlated and characterized by a critical juncture that generated a turning point for the cooperation (Pierson, 2000PIERSON, P. Increasing returns, path dependence, and the study of Politics. The American Political Science Review, Cambridge, v. 94, n. 2, p. 251-267, 2000.), but also by incremental changes triggered by public policies (Mahoney; Thelen, 2010MAHONEY, J.; THELEN, K. A theory of gradual institutional change. In: Explaining institutional change: ambiguity, agency, and power. Cambridge: Cambridge University Press, v. 1, p. 1-37, 2010.).

The critical juncture reflects the historical moment of the institution of a new government in Brazil in 2019, of a political position distinct from that of the immediately previous governments (of the PT), whose political projects move in opposite directions (Cohn, 2020COHN, A. As políticas de abate social no Brasil contemporâneo. Lua Nova, São Paulo, n. 109, p. 129-160, 2020.). The political-institutional dynamics produced in this new context allowed for the redefinition of institutions, as well as modifications in SUS public policies and in relations with other sectors of society, as can be expected in situations of institutional change, according to March and Olsen (2008MARCH, J. G.; OLSEN, J. P. Neo-institucionalismo: fatores organizacionais na vida política. Revista Sociologia Política, Curitiba, v. 16, n. 31, p. 121-142, 2008. DOI: 10.1590/S0104-44782008000200010
https://doi.org/10.1590/S0104-4478200800... ).

Similar to the creation of PMAQ-AB in 2011, its closure depended on a window of opportunity (Nogueira, 2006NOGUEIRA, F. A. Continuidade e descontinuidade administrativa em governos locais: fatores que sustentam a ação pública ao longo dos anos. Dissertação (Mestrado em Administração Pública e Governo) - Fundação Getúlio Vargas, São Paulo, 2006.). The program had already been resisting the Temer government’s political-institutional changes, for example, the adoption of EC-95, currently in force, which negatively affects the financing of health and education policies. Another change was the revision of the PNAB, target of criticism from several entities and actors in public/collective health. The legacy of these measures adds to the political and budgetary priorities set by the Bolsonaro government in 2019, inaugurating a new context, which has enabled more intense transformations in SUS. In AB, there has been a shift in the model of financing and payment by performance, which replaced PMAQ-AB with the PPB (Rede de Pesquisa em Atenção Primária à Saúde, 2019REDE DE PESQUISA EM ATENÇÃO PRIMÁRIA À SAÚDE. Contribuição dos pesquisadores da Rede APS ao debate sobre as recentes mudanças na política de atenção primária propostas pelo MS. Brasília: Rede APS, 2019.; Morosini; Fonseca; Baptista, 2020MOROSINI, M. V. G. C.; FONSECA, A. F.; BAPTISTA, T. W. F. Previne Brasil, agência de desenvolvimento da atenção primária e carteira de serviços: radicalização da política de privatização da atenção básica?. Cadernos de Saúde Pública, Rio de Janeiro, v. 36, n. 9, p. e00040220, 2020. DOI: 10.1590/0102-311X00040220
https://doi.org/10.1590/0102-311X0004022... ).

The end of the government-academy cooperation in PMAQ-AB, as a reflection of the alternation of government at the federal level and of political-institutional changes, is a common problem in the public sector in Brazil. In this case, the change of public managers in senior management tends to generate discontinuity of public policies and, almost always, the party-political bias prevails over other aspects, including technical ones, according to Nogueira (2006NOGUEIRA, F. A. Continuidade e descontinuidade administrativa em governos locais: fatores que sustentam a ação pública ao longo dos anos. Dissertação (Mestrado em Administração Pública e Governo) - Fundação Getúlio Vargas, São Paulo, 2006.). In the same direction as Rede APS (2019), Ferla (2020FERLA, A. A. O desenvolvimento do trabalho na atenção básica como política e como efeito pedagógico inusitado: movimentos do PMAQ-AB. In: AKERMAN, M. et al. (Org.). Atenção básica é o caminho!: desmontes, resistências e compromissos São Paulo: Hucitec , 2020. p. 94-124.) and Facchini (2020FACCHINI, L. A. PMAQ-AB: uma saga e seu fim. In: AKERMAN, M. et al. (Org.). Atenção básica é o caminho!: desmontes, resistências e compromissos. São Paulo: Hucitec, 2020. p. 25-38.), this research reveals that the interruption of this partnership is not an isolated event, but something that extrapolates the political-institutional processes of SUS. It reflects the phenomenon of discontinuity of Brazilian public policies in general, led by the country’s current administration, which began in 2019, and whose political project is to restrict social policies, especially in the fields of health and education (Cohn, 2020COHN, A. As políticas de abate social no Brasil contemporâneo. Lua Nova, São Paulo, n. 109, p. 129-160, 2020.). In this sense, Ferla (2020)FERLA, A. A. O desenvolvimento do trabalho na atenção básica como política e como efeito pedagógico inusitado: movimentos do PMAQ-AB. In: AKERMAN, M. et al. (Org.). Atenção básica é o caminho!: desmontes, resistências e compromissos São Paulo: Hucitec , 2020. p. 94-124. states that the discontinuity of the external evaluation of PMAQ-AB was processed in MS by a political group, not only because of technical issues, but because of divergence in policies.

It is noteworthy that the policy options or initial choices regarding the program evaluation process constituted the genesis of a group conflict, due to divergent conceptions, perspectives, and policy positions of the actors (Hall; Taylor, 2003HALL, P. A.; TAYLOR, R. C. R. As três versões do neo-institucionalismo. Lua Nova , São Paulo, n. 58, p. 193-223, 2003.; March; Olsen, 2008MARCH, J. G.; OLSEN, J. P. Neo-institucionalismo: fatores organizacionais na vida política. Revista Sociologia Política, Curitiba, v. 16, n. 31, p. 121-142, 2008. DOI: 10.1590/S0104-44782008000200010
https://doi.org/10.1590/S0104-4478200800... ). One of them was the political option for government-academy cooperation to make PMAQ-AB effective, assumed initially and sustained over the years by a political coalition. But in the face of a new conjuncture, with the change in the relative position of the actors, in terms of power and preferences about health policy, it was modified with the arrival of a new political group, which favored the suspension of cooperation (Pierson, 2000PIERSON, P. Increasing returns, path dependence, and the study of Politics. The American Political Science Review, Cambridge, v. 94, n. 2, p. 251-267, 2000.).

The decision to discontinue the cooperation promotes distancing between the actors of MS and the academy. Tomasi, Nedel, and Barbosa (2021TOMASI, E.; NEDEL, F. B.; BARBOSA, A. C. Q. Avaliação, Monitoramento e Melhoria da Qualidade na APS. APS em Revista, Belo Horizonte, v. 3, n. 2, p. 131-143, 2021. Disponível em: <Disponível em: https://apsemrevista.org/aps/article/view/208 >. Acesso em: 10 mar. 2022.
https://apsemrevista.org/aps/article/vie... ) interpret that today there is a divorce between SUS management and academia, a fact that makes a systemic action impossible and allows observing that the important results obtained with the institutional partnership have been discontinued in the current national political scenario.

This move by MS goes against contemporary practices, which aim to achieve better results in politics. We start from the premise that PMAQ-AB is a strategy with roots in more general movements to incorporate management by results in public administration. The focus of the program, aimed at improving the processes of the AB policy linked to the granting of financial benefits, translates the managerialism mode of operation, promoted in the management of public policies from the 1990s in Brazil. Also, in order to meet collective interests efficiently, government-academy institutional cooperation in PMAQ-AB consists of an alternative sharing of responsibilities that characterizes New Public Governance (Pereira et al., 2017PEREIRA, F. N. et al. Nova gestão pública e nova governança pública: uma análise conceitual comparativa. Espacios, Caracas, v. 38, n. 7, p. 6-26, 2017.).

The government’s investment in a closer relationship with the academy and with each other, is the mark of this institutional cooperation of PMAQ-AB, with recognized positive effects for SUS. This articulation, as a support to the policy of encouraging access and quality of AB for payment by performance, not only ensured the effectiveness of the program nationally, but also guided the construction of public health policies in the country, based on information that helps public managers in the decision-making process and generates benefits for the whole society (Cavalcanti; Fernandez; Gurgel Junior, 2021CAVALCANTI, P.; FERNANDEZ, M.; GURGEL JUNIOR, G. D. Cooperação entre academia e governo para avaliar a APS no SUS. Interface, Botucatu, v. 25, n. e210103, 2021. DOI: https://doi.org/10.1590/interface.210103
https://doi.org/https://doi.org/10.1590/... ; Facchini; Tomasi; Thumé, 2021FACCHINI, L. A.; TOMASI, E.; THUMÉ, E. (Org.). Acesso e qualidade na atenção básica brasileira: análise comparativa dos três ciclos da avaliação externa do PMAQ-AB, 2012-2018. São Leopoldo: Oikos, 2021.; Ferla, 2020FERLA, A. A. O desenvolvimento do trabalho na atenção básica como política e como efeito pedagógico inusitado: movimentos do PMAQ-AB. In: AKERMAN, M. et al. (Org.). Atenção básica é o caminho!: desmontes, resistências e compromissos São Paulo: Hucitec , 2020. p. 94-124.; Rede de Pesquisa em Atenção Primária à Saúde, 2018REDE DE PESQUISA EM ATENÇÃO PRIMÁRIA À SAÚDE. Contribuição para uma agenda política estratégica para a atenção primária à saúde no SUS. Saúde em Debate , Rio de Janeiro, v. 42, n. spe. 1, p. 406-430, 2018.; Tomasi; Nedel; Barbosa, 2021TOMASI, E.; NEDEL, F. B.; BARBOSA, A. C. Q. Avaliação, Monitoramento e Melhoria da Qualidade na APS. APS em Revista, Belo Horizonte, v. 3, n. 2, p. 131-143, 2021. Disponível em: <Disponível em: https://apsemrevista.org/aps/article/view/208 >. Acesso em: 10 mar. 2022.
https://apsemrevista.org/aps/article/vie... ). Therefore, this cooperative process has enabled greater integration between policy and science, in addition to the thickening of scientific knowledge and information for prompt use of the results for the improvement of the AB, in order to foster the development of IEPs (Ramos; Silva, 2018RAMOS, M. C.; SILVA, E. N. Como usar a abordagem da política informada por evidência na saúde pública?. Saúde em Debate, Rio de Janeiro, v. 42, n. 116, p. 296-306, 2018.; Primary Health Care Research Network, 2019; Facchini, 2020FACCHINI, L. A. PMAQ-AB: uma saga e seu fim. In: AKERMAN, M. et al. (Org.). Atenção básica é o caminho!: desmontes, resistências e compromissos. São Paulo: Hucitec, 2020. p. 25-38.; Cavalcanti; Fernandez; Gurgel Junior, 2021CAVALCANTI, P.; FERNANDEZ, M.; GURGEL JUNIOR, G. D. Cooperação entre academia e governo para avaliar a APS no SUS. Interface, Botucatu, v. 25, n. e210103, 2021. DOI: https://doi.org/10.1590/interface.210103
https://doi.org/https://doi.org/10.1590/... ).

The end of the cooperation occurred in a process marked by the absence of dialogue between MS and the partners in academy. Similar dynamics were highlighted by Morosini, Fonseca and Baptista (2020MOROSINI, M. V. G. C.; FONSECA, A. F.; BAPTISTA, T. W. F. Previne Brasil, agência de desenvolvimento da atenção primária e carteira de serviços: radicalização da política de privatização da atenção básica?. Cadernos de Saúde Pública, Rio de Janeiro, v. 36, n. 9, p. e00040220, 2020. DOI: 10.1590/0102-311X00040220
https://doi.org/10.1590/0102-311X0004022... ), when analyzing the political process of the creation of PPB, which occurred simultaneously with the end of the cooperation. According to the authors, the absence of interlocution, face-to-face participation, and representation of political actors has damaged public debate and hidden dissent, which “to a critical eye reveals the problems in the meaning and manner of doing politics.” Likewise, the National Health Council, users, and workers were absent from the debate (Neves; Machado, 2019NEVES, J; MACHADO, K. Atenção primária à saúde terá novo modelo de financiamento. Escola politécnica de saúde Joaquim Venâncio/fundação Oswaldo Cruz (EPSJV/Fiocruz), Rio de Janeiro:, 1 nov. 2019. Disponível em: <Disponível em: http://www.epsjv.fiocruz.br/noticias/reportagem/atencao-primaria-a-saude-tera-novo-modelo-de-financiamento >. Acesso em: 29 mar. 2022.
http://www.epsjv.fiocruz.br/noticias/rep... ; Morosini; Fonseca; Baptista, 2020MOROSINI, M. V. G. C.; FONSECA, A. F.; BAPTISTA, T. W. F. Previne Brasil, agência de desenvolvimento da atenção primária e carteira de serviços: radicalização da política de privatização da atenção básica?. Cadernos de Saúde Pública, Rio de Janeiro, v. 36, n. 9, p. e00040220, 2020. DOI: 10.1590/0102-311X00040220
https://doi.org/10.1590/0102-311X0004022... ).

Finally, the intention of this research is not to disregard the legitimacy of the government to act in the field of public health policies, according to its preferences and interests, even more so when there is express agreement with national representative bodies of SUS managers. Nor is the competence of the IBGE and the OECD in evaluative research questioned. As previously explained, the purpose of this work is to contribute to a better understanding about the dissolution of this government-academy institutional cooperation for the effectiveness of PMAQ-AB in SUS.

Final considerations

This research evidences that the end of institutional cooperation was processed within the political-institutional context of SUS, permeated by historical interferences that impacted the practices of public managers and the conduction of political processes. This scenario was strongly influenced by previous events, with effects on the future of the cooperation. Historically, academic institutions have collaborated in the evolution of Brazilian public health, from the sanitary reform movement until the moments after the creation of SUS. But in this process of ending the institutional cooperation in PMAQ-AB, dozens of partner IEPs were removed from the discussions regarding health policies.

It is also worth mentioning that, because it intends to capture more subjective aspects related to the interruption of cooperation, this article has limitations. Among them, one can mention sampling, which, due to the way the participants are selected, does not allow generalizations. In addition, the study does not capture the understanding of state and municipal managers about the process, limiting itself to the view of Conass and Conasems representatives. One difficulty in carrying out this work is related to the scarcity of studies that address the closure of PMAQ-AB, even more from the NH perspective or from another analytical approach from the field of Sociology. This is an initiative of approximation and dialogue, in order to contribute to the scientific knowledge about the discontinuity of policies in the field of Brazilian public health. Therefore, this work does not intend to go into all the aspects related to the theme, which would be justifiably impossible.

Still, the contributions of this research open an interesting window for further studies on SUS policies and programs, considering the political-institutional context of the country and the health field. In addition, they can also reflect on the performance of health authorities in the process of implementing public policies and their forms of interaction with sectors of society. This study especially reinforces that knowledge of past history allows for a better understanding of the present and foreshadows future developments, as NH points out.

The establishment of a process that brings together SUS and the academy will also depend on a context of political transformation and change of paradigm of public managers that, among other issues, values the power of this juncture as a collaborative network for the implementation of initiatives to improve the PCU, given the complexity and challenges of SUS. And that it also considers the effects of an interaction between the health and education subsystems for the development of research and for health training in schools. Therefore, an inter-institutional exchange for the development and execution of projects aiming at strengthening health management and supporting the institutional development of SUS, are future expectations. Considering the adversities imposed on the field of health and public education in Brazil today.

References

Publication Dates

History