Gestão compartilhada de recursos públicos da saúde: desafios para o desenvolvimento de um modelo de avaliação de implementação

Abstract

The management of the health system of the Federal District (DF) has sought to improve the responsive capacity of the state in providing health services to the population, in accordance with national guidelines for SUS. In particular, the principle of decentralization has been the object of intervention, in order to adapt it to the exercise of the concomitant functions of State and Municipality, proper to the Federal District. In 2010, the Federal District established the Progressive Decentralization of Health Actions Program (in Portuguese, Programa de Descentralização Progressiva das Ações de Saúde – PDPAS), through Decree No. 31,625 of April 29, 2010, whose operation takes place through the transfer of financial resources from the Federal District Health Fund (in Portuguese, Fundo de Saúde do Distrito Federal – FSDF) for the Assistance Units of the DF State Secretariat of Health, for the purchase of consumable and permanent materials, equipment, medicines and repairs to the physical facilities, in compliance with legal norms. OBJECTIVES: To analyze the evaluability of PDPAS implementation and its effects on SUS-DF based on information on budget execution and managers’ perceptions; identify actions that were decentralized to health units due to PDPAS in SUS-DF; verify the potentials and limits of PDPAS for the management of health units from the perspective of managers; propose an evaluation model and its effects; identify evaluable PDPAS components. METHOD: Evaluability study, through evaluative research based on mixed methods from the perspective of complementarity, in a problem-centered and pluralistic approach, which enables the use of research strategies with simultaneous data collection to better understand the research problems. The data collected were the amount of resources transferred and the budget execution of each care unit, document analysis of decrees, ordinances, audit reports of state control agencies, financial execution reports, spreadsheets with accountability summaries; interviews with PDPAS managers and technicians, conducted through a semi-structured script. Data were collected from September to December 2018. Quantitative data were analyzed using descriptive statistics, identifying the arithmetic mean of resources transferred and executed, by year and executing care unit. The interviews were transcribed from audio to text, returned to the interviewees for text confirmation, and subsequently subjected to thematic categorical content analysis. For the modeling of the Evaluability Study (in Portuguese, Estudo de Avaliabilidade – EA), the Problem Tree and the Logical Model were elaborated, which allowed the identification of evaluable PDPAS components. RESULTS: The aspects to be evaluated were divided into three dimensions – Structure, Process, Results – and analyzed according to the roles developed by the Central Administration (management unit) and Assistance Units (executors). In the Structure, the evaluable components in both units (manager and executor), should be the technical teams, information systems and information feedback. In the dimension Process, the regularity of the ADMC on lending process and the execution of resources in the executing units should be evaluated, with emphasis on the application of the parameters for the calculation of the values to be passed on according to the production record, the existence of norms, local knowledge and capacity to implement them, planning the decentralization process for the units. In the dimension Results, the regular supply of inputs and medicines and the reduction of the effects of drug purchases in a complementary manner to the ADMC are the evaluable intermediate results, among others. CONCLUSION: The identification of evaluable aspects of the program required the analysis of documents, data related to on lending and financial execution aligned with the managers’ perception on the dimensions Structure, Process and intermediate Results. The feasibility of a PDPAS evaluation through participatory and multi-method methodologies is pointed out, given the complexity of the design and implementation of the management intervention.