ABSTRACT

Regional health planning is a complex process conditioned by several factors, among which inequalities and federative relations stand out. In the context of the Covid-19 pandemic, these weaknesses in the federative and regional organization of the Unified Health System (SUS) have been acutely exposed, and accentuated by a scenario of incoordination and dismantlement of the institutional design conceived by the Federal Constitution of 1988. This essay aimed to draw reflections on some strategies built at the municipal, regional and state levels to tackle the pandemic, as a response to the political and institutional crisis, as well as to highlight current and future challenges. The work is based on syntheses of the discussions held during the preparatory workshop and the debate table of the IV Congress on Health Policies, Planning and Management of the Brazilian Association of Collective Health (Abrasco), on the theme of federative relations and regionalization in the scenario of the Covid-19 pandemic. The findings include: a lack of federal protagonism and the construction of delegated autonomy of subnational entities in the pandemic; the importance of some experiences of consortia and new partnerships with society; and the challenges and conditions of a new federative pact and new forms and designs to partner and support the organization of the SUS.

KEYWORDS
Regional health planning; Coronavirus; Health planning

Introduction

The territorial dimension of policies affects federations, countries with federalized mechanisms and even the functioning of multinational spaces, such as the European Union today. The impact of territorial politics can be observed in several countries, such as the United States, Italy, Spain, Germany, India, Mexico and Brazil. As some authors¹1 Abrucio FL, Grin EJ, Franzese C, et al. Combate à COVID-19 sob o federalismo bolsonarista: um caso de descoordenação intergovernamental. Rev Adm. Pública. 2020; 54(4):663-677.,²2 Região e Redes. O planejamento regional é estratégico no enfrentamento da pandemia da COVID-19. [acesso em 2021 jun 23]. Disponível em: https://www.resbr.net.br/
https://www.resbr.net.br/... have pointed out, in these countries, conflictual relations and cooperation between the national sphere and sub-national governments have to a large extent shaped recent public health policies against Covid-19. In some of these experiences, successful federal solutions explain part of the success in fighting the pandemic, as in the case of Germany³3 Pereira AMM. Estratégias de enfrentamento da pandemia pela COVID-19 no contexto internacional: reflexões para a ação. Nota Técnica. Observatório Fiocruz-COVID-19. Rio de Janeiro: Fiocruz; 2020. [acesso em 2021 jun 23]. Disponível em: https://portal.fiocruz.br/sites/portal.fiocruz.br/files/documentos/notatecnica_adelynepereiraestrategias_de_enfrentamento_da_pandemia_pela_COVID-19_no_contexto_internacional_reflexoes_para_a_acao.pdf
https://portal.fiocruz.br/sites/portal.f... . On the other hand, both in the US, under the Trump administration, and in Brazil, difficulties in tackling Covid-19 emerged, especially due to conflicts and a lack of intergovernmental coordination¹1 Abrucio FL, Grin EJ, Franzese C, et al. Combate à COVID-19 sob o federalismo bolsonarista: um caso de descoordenação intergovernamental. Rev Adm. Pública. 2020; 54(4):663-677..

Territorial policy is implemented on different territorial scales (such as by region and different sub-national spaces) and throughout history has introduced concepts with broad and distinct definitions. In a broad sense, the territorial scale reflects a system of actions and objects, manifested in an inseparable manner, at a certain historical time and space, and not simply an institutional or organizational system. These spaces serve as a platform for a diverse range of social, economic and political processes, as well as transformation trends, flows and networks promoted by the State, society, private agents, and others⁴4 Viana ALD’A, Iozzi FL. Enfrentando desigualdades na saúde: impasses e dilemas do processo de regionalização no Brasil. Cad. Saúde Pública. 2019; 35(supl2):e00022519..

In Brazil, even before the pandemic, no effective regional policies to reduce socio-spatial inequality had been consolidated. As the specialized literature widely points out, the implicit regional policies were far more virtuous than the explicit ones⁵5 Resende GM. Avaliação de políticas públicas no Brasil: uma análise da Política Nacional de Desenvolvimento Regional (PNDR). Brasília, DF: Instituto de Pesquisa Econômica Aplicada; 2017..

Since the turn of the 21st century, no strategy has been established aimed at comprehensive territorial development that would make intra- and inter-regional integration feasible, involving a coordinated, multi-scale dynamic, and based on social coalition and an alternative territorial approach. From this perspective, the development of regional connectivity and of fractions that consolidate oxygenating forms of territorially-based, bottom-up strategies must complement the forms of coordination, organization and anti-fragmentation reinforcement, typical of nationwide top-down logic⁶6 Fernández VR. Desenvolvimento regional sob transformações transescalares: por que e como recuperar a escala nacional? In: Brandão CA, Fernández VR, Ribeiro LCQ, organizadores. Escalas espaciais, reescalonamentos e estatalidades: lições e desafios para América Latina. Rio de Janeiro: Letra Capital; Observatório das Metrópoles; 2018. p. 276-325..

From the sectoral point of view, in the same period (1988-2020), social policies and health policies in particular were also challenged by a lack of scalar and institutional integration.

Throughout its 30 years of implementation, the Unified Health System (SUS) has experienced different political cycles guided by decentralization and regionalization, with distinct forms of intervention in the area of promotion, prevention and care (including primary care, and moderate and high complexity care). Its last phase, in which the health regions and care networks were configured, involved the construction of a regional space for collegiate management - the Regional Intermanagement Commissions (CIR) - in all Brazilian states. Financially it was supported by contributions from subnational entities in a context of permanent retraction from the federal sphere.

It should be noted that the two organizational cycles of the SUS developed in distinct political, economic and social contexts. The first cycle is dominated by the decentralization of services, professionals and of some functions (administrative and regulatory) to the Brazilian municipalities. In the second cycle, meanwhile, there is emphasis on constructing the regions and health care networks. The political context of the first cycle was inaugurated with the emergence of a new Federal Constitution⁷7 Viana ALD’A, Silva HP. Desenvolvimento e institucionalidade da política social no Brasil. In: Machado CV, Baptista TWF, Lima LD, organizadores. Políticas de saúde no Brasil: continuidades e mudanças. Rio de Janeiro: Editora Fiocruz; 2012. p. 31-60., which gave rise to the principles and guidelines of the new system and to democratic governments, with neoliberal policies steering the economy and a social policy agenda focused on decentralization in the 1990s. The second cycle, on the other hand, displays a hybrid character, with continued neoliberal management of the economy, and the return of the regional aspect to the economic and social agendas (in the first two decades of the 21st century).

The regionalization cycle of the health policy can be seen in four successive periods: 1) early 2000s until 2006, focused on the construction of sectorial instruments to regulate the process, with emphasis on the Operational Health Care Standard - Noas in 2002; 2) 2006-2012 (Pact for Health), when the subject of regionalization progressed to an intersectoral scale and supplemented the debate on regional development; 3) 2012-2016 (Decree no. 7.508 and Supplementary Law no. 141), continued discussion of regional development, interrupted by the economic and political crisis, which culminated in the impeachment of the elected president; 4) 2018 to the present day, marked by the dismantling of the political and institutional framework of post-1988 Federal Constitution public policies, with the publication of several laws, decrees and ordinances, shaking up federative relations and causing significant disorder in the political system, with the end of ‘coalition presidentialism’ - the political dynamic that organized political and institutional relations⁸8 Abranches S. Presidencialismo de Coalizão: Raízes e Evolução do Modelo Político. São Paulo: Companhia das letras; 2020. and was deepened with the federative pact of the 1988 Federal Constitution.

Recent national studies conducted on the theme of regionalization have highlighted the importance of constructing other elements, variables and criteria for the formulation of territorial planning in health. These studies indicate that there remains a strong concentration of services and resources in hub municipalities and that the Atlantic territorial configuration (the South, Southeast and Northeast coastlines) continues to concentrate the majority of services and technologies⁹9 Mello GA, Pereira APC, Uchimura LYT, et al. O processo de regionalização do SUS: revisão sistemática. Ciênc. Saúde Colet. 2017; 22(4):1291-1310. Disponível em: http://dx.doi.org/10.1590/1413-81232017224.26522016
http://dx.doi.org/10.1590/1413-812320172... .

These studies suggest that there have been insufficient efforts to form the regions and care networks, both in the political dimension - due primarily to the weak role played by the state through its regional structures - and in the structural dimension, in which inequalities are demonstrated by the scarce distribution of resources and the high concentration of services in large cities; or even in the organizational dimension, in which there is the different points of care are poorly integrated and regional planning is limited. Another problem identified was the failure to join economic and social development and technological and knowledge-focused efforts towards more self-sufficient regions.

For this reason, the health care regionalization process in Brazil differs from those implemented in developed countries, which are strongly focused on the construction of integrated care systems and networks. International studies on the theme of regionalization indicate that developed countries encourage the organization of patient-centered health care systems, capable of responding to epidemiological challenges and the best service performance. In Brazil, problems of a structural nature exacerbate a deficient supply of equipment and specialties (human and technological resources) throughout the territory, bringing to the fore the issue of territorial equity as the biggest challenge to be faced to fulfill the guideline of comprehensiveness of the SUS.

Recent federal and state policies positioned in favor of the emergence of a system operated in the network format have placed Brazil in the position of (some) contemporaneity with the international profile, by defining that the organization of care within health systems would be operated by networks, aimed at the construction of integrated health systems.

It should be noted that the networks become the bearers of a new management and organizational logic for the health services, and can facilitate integration from the territorial point of view or further fragment the system in the region. At least two interconnected factors are highlighted here as the drivers of this misalignment: the disconnection between the thematic networks (not functioning systematically) and the lack of a user-focused development of this integration.

Another aspect is the entrepreneurial nature of the supply of health services, since this legal form of contract for the management of equipment has spread throughout the country, so as to cover different levels of care. Under the aegis of private law, the weight institutional segments grew intensely between 2005 and 2020, which attests to the fact that local management in Brazil is also characterized by a stronger presence of private actors in the management of certain policies.

Furthermore, current studies show the difficulty in reaching consensus among the federative entities due to their high degree of complexity, involving conditions such as: inequality in the spatial distribution of equipment, supplies and technologies, and limited availability of human and financial resources; difficulties in the regional integration of public policies and State actions in the various fields of health care; and the diversity of the agents (governmental and nongovernmental, public and private) active in service provision and management in the territory¹⁰10 Viana ALD’A, Ferreira MP, Cutrim MAB, et al. O Processo de Regionalização no Brasil: influência das dimensões Política, Estrutura e Organização. Rev Bras Saúde Mater. Infant. 2017; 17(supl1):27-43.

11 Albuquerque MV, Lima LD, Oliveira RAD, et al. Governança regional do sistema de saúde no Brasil: configurações de atores e papel das Comissões Intergovernamentais. Ciênc. Saúde Colet. 2018; 23(10):3151-61.

12 Ibañez N, Tardelli R, Viana ALD’A, et al. Gestão regional e redes: estratégias para a saúde em São Paulo. São Paulo: Edições Manole; Secretaria de Estado de Saúde de São Paulo; 2020.-¹³13 Noronha JC, Lima LD, Chorny AH, et al, organizadores. Brasil Saúde Amanhã: dimensões para o planejamento da atenção à saúde. Rio de Janeiro: Editora Fiocruz; 2017..

With the Covid-19 pandemic, this scenario worsened due to the institutional and political crisis and the pressing need to establish an equal and equitable division of health resources, whether they be financial, human, technological or installed capacity¹⁴14 Vieira F, Servo L. COVID-19 e coordenação federativa no Brasil: consequências da dissonância federal para a resposta à pandemia. Saúde debate. 2020; 44(esp4):100-113..

The clashes between the President of the Republic and governors and mayors led to the judicialization of the issue, with the Federal Supreme Court (STF) ruling that the competence of the Federal Government, the states, the Federal District and the municipalities is concurrent in health matters and, therefore, all entities of the federation have autonomy¹⁴14 Vieira F, Servo L. COVID-19 e coordenação federativa no Brasil: consequências da dissonância federal para a resposta à pandemia. Saúde debate. 2020; 44(esp4):100-113. to take normative and administrative measures related to Covid-19. However, this decision neither put an end to the discrepancies nor generate space for expanded federal coordination in the fight against the pandemic.

Consequently, a fragmented setting with a chaotic political system prevails, with various responses from governmental entities and lack of any national coordination to tackle the pandemic. For the first time, during the year of a pandemic, Brazil had a military man as the main health authority, who was, therefore outside party-political dynamics. This fact further aggravated the uncoordinated federative outlook, leading to a failure of the Brazilian policy to combat Covid-19.

This essay aims to draw reflections on some strategies built at the municipal, regional and state levels to tackle the pandemic, as a response to the political and institutional crisis, as well as to highlight some current and future challenges. The work is based on syntheses of the discussions held during the preparatory workshop and the debate table of the IV Congress on Health Policies, Planning and Management of the Brazilian Association of Collective Health (Abrasco), on the theme of federative relations and regionalization in the scenario of the Covid-19 pandemic.

Absence of federal protagonism and the construction of (delegated) autonomy of sub-national entities in the pandemic

Federal or intergovernmental coordination refers to the forms of integration, sharing and joint decision making fount in federations¹⁵15 Abrucio FL. A coordenação Federativa no Brasil: a experiência do período FHC e os desafios do governo Lula. Rev Soc. Política. 2005; 24(41):41-67.,¹⁶16 Lima LD. A coordenação federativa do sistema público de saúde no Brasil. In: Fundação Oswaldo Cruz. A saúde no Brasil em 2030: organização e gestão do sistema de saúde. v. 3. Rio de Janeiro: Fiocruz; Ipea; Ministério da Saúde; Presidência da República; 2013. p. 73-139., fundamental aspects to ensure the balance between interdependence and federative autonomy, and decisive condition for tackling the health crisis inherent to the Covid-19 pandemic.

The pandemic accentuated the transformation of the state model adopted in many countries¹⁷17 Vidal JP. Pandemia de COVID-19 y Estado: ¿Hacia una nueva la configuración administración-Estado? Cad. EBAPE.BR. 2020; 18(4):924-935.. Thus, the gravity of the situation, characterized by the inherent complexity of modern societies, constituted by an extensive and dense political, administrative and legal organization at multiple levels¹⁷17 Vidal JP. Pandemia de COVID-19 y Estado: ¿Hacia una nueva la configuración administración-Estado? Cad. EBAPE.BR. 2020; 18(4):924-935., required and continues to require State presence in all spheres.

In Brazil, since the outbreak of the pandemic, the federal government has failed to display protagonism in its actions, especially as regards coordination of the three levels of government. On the contrary, a negationist attitude¹⁸18 Morel APM. Negacionismo da COVID-19 e educação popular em saúde: para além da necropolítica. Trab. Educ. Saúde. 2021; (19):e00315147.,¹⁹19 Apostolidis T, Santos F, Kalampalikis N. Society against COVID-19: challenges for the socio-genetic point of view of social representations. Papers on Soc. Represent. 2020; 29(2):3.1-3.14. was observed, led by the President of the Republic, which caused uneasy dialogue and disagreements with the other federative entities (states and municipalities). This situation has been compounded by the minister of health being changed four times so far.

The following activities are seen to be essential in the various countries’ responses to Covid-19: i) coordinated and consistent stay-at-home orders across all jurisdictions; ii) rapid testing for identification of the new coronavirus; iii) improved health system responsiveness¹⁴14 Vieira F, Servo L. COVID-19 e coordenação federativa no Brasil: consequências da dissonância federal para a resposta à pandemia. Saúde debate. 2020; 44(esp4):100-113.. These actions have not been implemented in an adequate and timely manner, mainly due to the lack of coordination at the federal level, which has strongly affected most states and municipalities, leading them to take solitary decisions, many of which are correct and others innocuous or harmful, in the face of the need to tackle the disease, with a growing number of infections and deaths.

Initially, the Ministry of Health (MS) sought to carry out actions focused on the area of health surveillance, including the declaration of a Public Health Emergency of National Importance, with the creation of an executive inter-ministerial group, publication of notices for the acquisition of Personal Protection Equipment (PPE) and issuance of epidemiological bulletins. However, successive disagreements between the MS and the Presidency of the Republic led to deadlocks and delays in the application of federal resources in actions aimed at fighting the pandemic²⁰20 Croda JHR, Garcia LP. Resposta imediata da Vigilância em Saúde à epidemia da COVID-19. Epidemiol. Serv. Saúde. 2020; 29(1):e2020002.50.,²¹21 Afonso JR, Pinto EG. A velha falta de prioridade e uma nova tragédia anunciada. Poder 360. 2020 maio 18. [acesso em 2020 jun 12]. Disponível em: https://bit.ly/2Atrp9R
https://bit.ly/2Atrp9R... .

Moreover, a failure to listen to the states and municipalities in the instances of representation, as well as in the development of standards for the system involving the representation of all three spheres of government, triggered an escalation of conflicts in the tripartite relationship, among which, we can highlight: a) The federal government’s failure to give due recognition to the importance of state representative bodies - the National Council of H ealth Secretaries (Conass) - and municipalities - the National Council of Municipal Health Secretaries (Conasems) - for SUS management and for coordinating pandemic response actions²²22 Brasilino CE. Conselhos de secretários de Saúde são barrados na posse de Teich: Ministro enviou ofício aos presidentes do Conass e do Conasems onde pede desculpas pelo constrangimento ocorrido na cerimônia no Planalto. Metrópoles 2020. [acesso em 2020 jun 12]. Disponível em: https://bit.ly/3cUwYLQ
https://bit.ly/3cUwYLQ... .

b) Resignation of the President of Conass, Alberto Beltrame, due to the lack of coordination of the MS in the purchase of equipment, medicines, supplies and increase of ICU beds in the context of the Covid-19 pandemic²³23 Conselho Nacional de Secretários de Saúde. Nota oficial: renúncia do presidente Alberto Beltrame. [acesso em 2020 jun 12]. Disponível https://www.conass.org.br/nota-oficial-renuncia-do-presidente-alberto-beltrame/
https://www.conass.org.br/nota-oficial-r... .

c) Publication of guidance for the use of chloroquine and hydroxychloroquine in the treatment of Covid-19, in breach of the standard that requires analysis by the National Commission for the Incorporation of Health Technologies²⁴24 Brasil. Ministério da Saúde. Orientações do Ministério da Saúde para manuseio medicamentoso precoce de pacientes com diagnóstico da COVID-19. Brasília, DF: Ministério da Saúde; 2020. [acesso em 2020 jun 12]. Disponível em: https://www.gov.br/saude/pt-br
https://www.gov.br/saude/pt-br... .

d) Delayed disclosure of data and modified methodology for the recording deaths by Covid-19; which situation led Conass to launch a panel to present the numbers of cases and deaths²⁵25 Conselho Nacional de Secretários de Saúde. Painel Conass: COVID-19. Brasília, DF: Conass; 2020. [acesso em 2020 jun 12]. Disponível em: https://www.conass.org.br/painelconassCOVID-19/
https://www.conass.org.br/painelconassCO... .

e) Cancellation of ventilator purchases and of contracts to increase the number of ICU beds by the MS²⁶26 Bertoni E. Os atrasos e omissões de um Ministro da Saúde provisório. Nexo Jornal. 2020 jun 1. [acesso em 2020 jun 12]. Disponível em: https://www.nexojornal.com.br/expresso/2020/06/01
https://www.nexojornal.com.br/expresso/2... .

f) Publication of the Conass Letter (1 March 2021) demanding stricter measures to restrict non-essential activities, according to the epidemiological situation and service capacity of each region, evaluated weekly, and based on technical criteria²⁷27 Conselho Nacional de Secretários de Saúde. Carta dos Secretários Estaduais de Saúde à Nação Brasileira. Brasília, DF: Conass; 2021. [acesso em 2020 jun 12]. Disponível em: https://www.conass.org.br/carta-dos-secretarios-estaduais-de-saude-a-nacao-brasileira/
https://www.conass.org.br/carta-dos-secr... .

g) A letter published by collective health and bioethical entities, expressing support for the position taken by Conass and Conasems, which was critical of the timing of the agreement and publication of a Risk Matrix, proposed by the current Minister of Health, to instruct a loosening of the social distancing rules in the country²⁸28 Carta em apoio ao CONASS e CONASEMS: A saúde e a vida das pessoas não podem esperar. 2020. [acesso em 2020 jun 12]. Disponível: https://www.abrasco.org.br/site/wp-content/uploads/2020/05/Carta-em-apoio-ao-Conass-e-Conasems-A-SA%C3%9ADE-E-A-VIDA-DAS-PESSOAS-N%C3%83O-PODE-ESPERAR-1.pdf
https://www.abrasco.org.br/site/wp-conte... .

These situations have pushed states and municipalities to, together and/or separately, take on a central role in coordinating the response to the pandemic. This occurred with great difficulty, since the position adopted by the MS amplified the asymmetry of power, resulting in poor coordination, which led to the removal of its responsibilities and its harnesses over the agencies of control. It also generated discontinuity in a number of situations in relation to guaranteeing the provision of, for example, laboratory testing, medication kits for intubation, medical oxygen, PPE, and ICU beds. This resulted in deficient coordination and inefficient development, compromising the effectiveness of health care and surveillance actions. This set of circumstances led Brazil, with more than 500,000 deaths, to become the epicenter of the pandemic in March 2021.

Finally, while on the one hand, the increased participation of states and municipalities proved to be, in a way, positive and important in tackling the pandemic; on the other hand, the importance of a tripartite coordination was made clear, with the MS as a guiding hand in the organization of practices and tripartite cooperation processes, capable of expanding federative capacity to tackle a common enemy: Covid-19.

Experiences of consortia and new partnerships with society

The need for regional planning and scheduling of health services has been pointed out in the context of SUS management since the early 2000s; this became more evident in the context of the pandemic, especially due to the lack of coordination by the MS to implement extensive measures that involved the organization of the different entities for tackling the crisis.

It is highlighted that regionalization, indicated in the normative context of the SUS as necessary for guaranteeing comprehensive care, demands technical-political efforts for its effectiveness. The Public Health Consortia were established as organizational arrangements between municipal entities in this perspective, and have a relevant supporting role. They provide the opportunity to rediscuss the federative pact, in the sense of identifying weak points in the region, to verify where they can act regionally and in an organized manner, to tackle common challenges.

This experience, initially developed by the municipalities, inspired other modalities of consortia between entities. One of these new modalities is the Vertical Consortium, involving the State of Ceará and the municipalities of that state. The consortia in Ceará were implemented containing the municipalities of the region and the state as their members; their organizational structure is differentiated from the entities and they are set up as public associations with autonomous local authority²⁹29 Julião KS, Olivieri C. Cooperação intergovernamental na política de saúde: a experiência dos consórcios públicos verticais no Ceará, Brasil. Cad. Saúde Pública. 2020 [acesso em 2021 abr 10]; 36(3):e00037519. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0102-311X2020000305001&lng=en
http://www.scielo.br/scielo.php?script=s... .

Established to enable the implementation of specialized care in the interior of the state, they were fundamental in the organization of hospital care for Covid-19. In this regard, the consortia supported a restructuring of the hospital service network, starting with the state’s own hospitals, accelerating the offer of beds that were being built, and allocating beds and equipment to all the health regions, in their own hospitals and establishments owned by private and philanthropic providers. Acting in this manner enabled the more distant regions of the capital of Ceará to be more involved in the health policies and to organize themselves more swiftly than neighboring regions.

Another more recent modality of consortium between the entities is the Northeast Consortium, which is the most successful experience of coordination and cooperation between entities to tackle the pandemic. The North East Sustainable Development Consortium was established in 2019, is public in nature and currently brings together nine states. Its purpose is to promote sustainable development and cooperation among the consorted entities, ensuring, for example, economies of scale in the contracting of goods and services and in the development of actions, under an inter-federative pact arrangement³⁰30 Consórcio Nordeste. Ações de Combate à Pandemia 2021. [acesso em 2021 jun 19]. Disponível em: http://www.consorcionordeste-ne.com.br/compras-conjuntas-combate-a-pandemia/
http://www.consorcionordeste-ne.com.br/c... .

The experiences of existing municipal consortia contributed to the Northeast Consortium learning about the logic and dynamics of consorted entities, guiding the way and showing which objectives should be pursued. Another fact that supported the consortia was the existence of the Northeast Governors Forum, which has existed since 2004²⁹29 Julião KS, Olivieri C. Cooperação intergovernamental na política de saúde: a experiência dos consórcios públicos verticais no Ceará, Brasil. Cad. Saúde Pública. 2020 [acesso em 2021 abr 10]; 36(3):e00037519. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0102-311X2020000305001&lng=en
http://www.scielo.br/scielo.php?script=s... . This forum would meet and discuss challenges and plans, but had no management. Since the 2018 elections, the governors have understood that the consortium could be a management tool. The nine Northeastern governors, although from six different parties, are strongly united by the feeling, challenges, needs, and problems faced in their states; so there are many common elements in the region that favor cohesion among the state governors.

In relation to the performance of the Northeast Consortium in the context of the pandemic, it is worth considering that, although there was pressure from the governors for the central government to adopt coordination actions, this proposal was denied. None of the ministers who took office took steps in this direction, and the states felt left to their own devices. Thus, they had to develop actions for which they were not prepared, such as international purchases. Many states have fallen victim to scams in this area of procurement because they had no expertise or experience of this kind of operation.

To overcome this situation, a ‘Scientific Committee’ was established to advise the consortium states on the adoption of measures for the prevention, control and containment of risks, damages and injuries to public health, as well as to contribute to the structuring of the health system to serve the population³⁰30 Consórcio Nordeste. Ações de Combate à Pandemia 2021. [acesso em 2021 jun 19]. Disponível em: http://www.consorcionordeste-ne.com.br/compras-conjuntas-combate-a-pandemia/
http://www.consorcionordeste-ne.com.br/c... .

The current vaccination issue (a sad episode) was the result of extensive coordination work by the Northeast Consortium, through Governor Wellington Dias (Piauí), with the other governors, the President of the Republic and the Minister of Health, for the purchase of vaccines, according to the needs of the country, regardless of the origin, provided their safety was proven. Once the agreement was made, a meeting was held in Brasilia at the Ministry of Health, attended by the National Health Surveillance Agency (Anvisa) and the Oswaldo Cruz Foundation (Fiocruz). Everything had been agreed, but due to pressure from his followers and international pressure, the President backtracked and vetoed the purchase of the Chinese vaccine. All this made the challenge even greater, as governors began to prepare for the need to buy directly for their region, despite it being considered incorrect to make purchases for a single region of Brazil.

It should be noted that the understanding is that the MS has legal constitutional responsibility for national coordination and that had this action gone through, the health situation in Brazil would likely be different to that being experienced today. Therefore, it is necessary to continue demanding this posture from the Ministry. However, to overcome, albeit partially, the lack of leadership and national coordination by the federal government, other forms of organization were put into effect during this period. The Legal Amazon Consortium was created, the operations of an existing consortium, the Brazil Central Consortium, were ramped up, and the National Governors Forum was also reactivated.

One lesson learned is that the consortia have played an important role in the entities’ joint tackling of the pandemic, following a logic of collaboration and shared management, focused on health care for the people. However, the discussion of the federative pact needs to be revisited. There are many distortions that need correcting; and currently it is necessary to identify the weaknesses, where and how we can advance and how society will reach another level that will distance the country from the current catastrophic situation.

Conditioning factors, challenges and prospects for improving SUS federative governance

The Covid-19 pandemic accentuated the scenario of political instability in Brazil, triggering a crisis marked by clashes between governments, uncoordinated policies and the judicialization of federative relations¹1 Abrucio FL, Grin EJ, Franzese C, et al. Combate à COVID-19 sob o federalismo bolsonarista: um caso de descoordenação intergovernamental. Rev Adm. Pública. 2020; 54(4):663-677.. As conditioning factors of the crisis, one can highlight the existence of a systematic political project to dismantle and weaken State capacity for public intervention, which has been put into effect in the country since 2016. This neoliberal-leaning project is anchored on an authoritarian economic development model, subordinate to and dependent on central economies in the global scenario, of a concentrating and excluding nature, which generates and worsens inequalities, ravages the environment and disregards life. We can further highlight political and institutional factors, related to the dissonant performance of the federal government as regards pandemic control and mitigation measures, the specific characteristics of the federative arrangement and the dismantling of the institutional arrangement established by the 1988 Federal Constitution¹⁴14 Vieira F, Servo L. COVID-19 e coordenação federativa no Brasil: consequências da dissonância federal para a resposta à pandemia. Saúde debate. 2020; 44(esp4):100-113.,³¹31 Lima LD, Pereira AMM, Machado CV. Crise, condicionantes e desafios de coordenação do Estado federativo brasileiro no contexto da COVID-19. Cad. Saúde Pública. 2020; 36(7):e001852200..

In this context, several states and municipalities have developed their own strategies and mechanisms to mitigate the lack of leadership and national coordination and to strengthen intergovernmental cooperation on different regional scales. However, such measures lose effectiveness and tend to reinforce iniquity between the entities, against a backdrop of socio-spatial inequalities and weakening of the State and the SUS itself, with the imposition of chronic underfunding and spending cuts in social policy forced by Constitutional Amendment No. 95.

Currently, the Brazilian federation finds itself at a crossroads. What choices must be made and what are the prospects for the federative pact in health? First and foremost, it is necessary to alter the directionality of the State’s role. The basis for this transformation involves a new social pact, sustained by different actors from the State and society, in defense of democracy and life. In this project, certainly, the SUS should have a prominent place and needs to be strengthened through its governance arrangement.

Governance arrangements encompass the actors, structures and processes that shape the exercise of authority and public policy decisions³²32 Rhodes RAW. The new governance: governing without government. Political Studies. 1996; (XLIV):652-67.,³³33 Stoker G. Governance as theory: five propositions. Int Soc Sci J. 1998; 50(155):17-28.. The experiences developed, internationally and domestically, in the context of the pandemic, suggest four strategic axes for the future improvement of the political-institutional framework for SUS governance: 1. strengthening of the command and coordination structures; 2. clear assignment of managerial roles and responsibilities; 3. increased mechanisms for inter-governmental cooperation; 4. coordination of information flows and communication actions with society regarding the health situation, decisions and actions to address the emergency, in a timely, inclusive and transparent manner, as per figure 1 below.

The first axis highlights the importance of strengthening the command and coordination structures at each level of government, between different spheres of government, and involving various State and civil organizations. The SUS institutional management framework consists of tripartite, bipartite and regional intergovernmental commissions (CIT, CIB and CIR, respectively) and Representative Councils for Municipal and State Health Departments (Conass, Conasems and Municipal Health Department Councils).

These are structures for the negotiation and formulation of health policies, involving the participation of different spheres of government. These characteristics shape them as forums, which need to be treated as spaces for planning policies and joint actions among SUS managers, prioritizing the development of a negotiation agenda aimed at integrating policies and services (health care networks), promoting investments and dealing with specific geographical situations (metropolitan regions, international and interstate border areas, areas of environmental protection and indigenous reserves, among others). Furthermore, they support the exchange of experiences between states and municipalities, opening up space for technical cooperation between them. The Intermanagement Commissions must be supported by Advisory Committees, composed of specialists and representatives of movements, organizations and bodies representing civil society. The committees should also work in coordination with the Health Councils in the different spheres of government.

The second strategic axis refers to the clear definition of responsibilities and management functions, based on national, state and regional plans agreed between the entities. The managers’ responsibilities include the creation of mechanisms for monitoring the measures implemented and their results and for providing information to and continuously communicating with the society at large. The federative entities’ responsibilities must be defined considering the degree of effectiveness that can be achieved through the concentration or decentralization of the functions required for achieving the planned objectives. It is considered a primary function of the Federal Government to ensure adequate funding of the SUS. In addition, the MS is responsible for coordinating actions with the Ministries of Economy and Labor, among others, to provide guarantees for the social and economic protection of the population.

The third axis highlights the need to increase intergovernmental cooperation mechanisms aimed at strengthening the political and institutional capacities of governments at the sub-national level. In this sense, two elements are fundamental: the expansion of direct spending and transfers from the federal sphere to states and municipalities, which make it possible to compensate for losses in revenue and ensure investments and adequate funding of services; and the strengthening of vertical (with the participation of different levels of government) and horizontal (intermunicipal and interstate) public consortia, whose actions in the health area are coordinated with the Intermanagement Commissions, with the aim of scaling up the provision of policies and actions.

Finally, a fourth important axis is that of information and social communication. This dimension involves aspects such as the availability of reliable health information for the entire population, in a timely and continuous manner, and in language that is accessible and appropriate for different social groups. In federative countries like Brazil, the speedy flow of information between governments of different spheres is fundamental, as is the coordination of public communication actions related to the epidemiological situation, the health system scenario and the strategies for dealing with health emergencies. The SUS envelops relevant information systems of various types, including in the area of health surveillance, which must feed strategic analyses to guide decision-making and enable clear and well-founded communication with society.

However, recognizing that political-institutional arrangements matter for the improvement of SUS governance is not the same as saying that only institutions matter. There is no political system that functions independently of the choices and definition of aims and strategies of the political actors that sustain it. The transformations described above require alliances based on a common positive agenda to reverse the current outlook of dismantlement and redirect the State’s action in a situation marked by enormous challenges for the advancement of public policies and the SUS.

Final considerations

The Covid-19 pandemic brought to the fore the worsening of the institutional and political crisis in Brazil, showing, as highlighted in this essay, the difficulty in reaching consensus among the federated entities. In this sense, and in relation to the actions implemented on states and municipalities, one must highlight the negationist posture toward the pandemic adopted by the head of the national executive and the mismanagement of the situation by the Ministry of Health, aggravated by successive substitutions of health minister.

We have, therefore, witnessed the embodiment of numerous clashes between the President of the Republic with governors and mayors, a situation that increased the tension, leading the issue to be taken to the Federal Supreme Court (STF), which judged that the federated entities are autonomous in relation to the adoption of normative and administrative provisions related to Covid-19. Nevertheless, neither the disagreements were settled nor was the channel of dialogue broadened to improve federative coordination in the fight against the pandemic.

We can thus observe and deduce that the consequences of such situations have led to a context of further fragmentation and chaos in the health system, bringing about various consequences that have exacerbated the situation of federative disconnection, and contributing to the failure of the Brazilian policy to combat the Covid-19 pandemic.

This situation forced the federated entities to seek ways and solutions to tackle the pandemic, a process strongly led by the publication of norms (decrees and laws) in different fields of intervention: from territorial management to regulation, from the development of health policies and the expansion of services to the protection of jobs, income and finances. With regard to the health sector, we have seen managers strongly advocating and following the directives issued by the World Health Organization for social isolation, the adoption of measures to restrict the movement and gathering of large numbers of people in order to avoid the collapse of the health sector, based on epidemiological and crisis management guidelines.

The managers sought to organize themselves, and in this context, the actions of Conass and Conasems were extremely important in maintaining the federative balance. The development of some consortia and new partnerships with society, which proved to be relevant, should also be highlighted.

However, there are still challenges and necessary conditions for a new federative pact that can effectively contribute to fighting the pandemic and overcoming the consequences it will leave for the health sector and society. Overcoming this situation requires a change of course, which includes transforming the directionality of the State’s role. It also requires different political forces and actors from the State and society to mobilize around a new social pact, in defense of democracy, and of reinforcing the SUS and life.

Acknowledgements

Lima LD is a research productivity fellow and Scientist of Our State and is grateful for the support received, respectively, from the National Council for Scientific and Technological Development (CNPq) and the Foundation for Research Support of Rio de Janeiro (Faperj). Shimizu H is a CNPq productivity fellow and is grateful for the research support received from the CNPq and Decit/MS.

References

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