Institutional arrangements and state capacity in the Program More Doctors

Esta pesquisa procurou analisar as implicações dos inter-relacionamentos dos arranjos institucionais e das capacidades estatais na implementação e nos resultados do Programa Mais Médicos (PMM), iniciado em 2013, bem como avaliar a sua efetividade em promover mudanças nos resultados da Atenção Básica (AB) à saúde. Neste sentido, três estudos independentes, porém, complementares, foram desenvolvidos. No primeiro, estudou-se o processo de implementação do eixo emergencial do PMM, analisando as capacidades estatais (técnico-administrativas e político relacionais) mobilizadas ou não pelo arranjo institucional do programa. A partir de entrevistas semiestruturas e de análise documental constatou-se que num primeiro momento, logo após a implantação do programa, o mesmo tinha centralidade política na agenda governamental e apoio popular e de gestores. Assim, o arranjo favoreceu a mobilização de capacidades estatais. Porém, mudanças de atores centrais no arranjo de implementação após a ruptura governamental no ano de 2016, em função do contexto sociopolítico, aliado a pressão de grupos de interesses, enfraqueceu as capacidades estatais de implementação do Mais Médicos. No segundo estudo, analisou-se o processo alocativo de médicos pelo PMM, se o mesmo foi orientado por critérios equitativos. A partir da construção do Índice de Vulnerabilidade e Condições de Saúde (IVCS), com variáveis socioeconômicas e de saúde dos municípios brasileiros em dois momentos do tempo, anterior a implementação do PMM, no ano de 2012 e, posteriormente, no ano de 2015, procedeu-se com a alocação de médicos considerando o indicador proposto. Os resultados mostraram que o PMM contribuiu para reduzir as desigualdades regionais de disponibilidade de médicos ao alocá-los em municípios com severa e alta vulnerabilidade no IVCS, de pequeno porte populacional e aqueles situados nas regiões Norte e Nordeste do país. Esse conjunto de municípios eram os mais necessitados e, portanto, foram priorizados. Entretanto, as evidências também apontaram falhas no processo alocativo e diminuição da oferta regular de médicos. Por fim, o último estudo analisou os efeitos do PMM a partir de estudos quase-experimentais em alguns indicadores de saúde de municípios em situação de alta e severa vulnerabilidade, considerando o IVCS do ano de 2012.This research sought to analyze the implications of the interrelationships between institutional arrangements and state capacity in the implementation and results of the Program More Doctors (PMM), initiated in 2013, as well as to evaluate their effectiveness in promoting changes in the results of Primary Health Care (PHC). In this sense, three independent but complementary studies were developed. In the first one, the process of implementing the PMM's emergency axis was studied, analyzing the state capacity (technical-administrative and political relational) mobilized or not by the institutional arrangement of the program. Based on semi-structured interviews and documental analysis, it was found that at the outset, soon after the implementation of the program, it had political centrality in the governmental agenda and popular support and managers. Thus, the arrangement favored the mobilization of state capacities. However, changes of central actors in the implementation arrangement after the government's disruption in 2016, due to the socio-political context, coupled with pressure from interest groups, weakened the state's capacity to implement More Doctors. In the second study, it was analyzed the allocative process of physicians by PMM, if it was guided by equitable criteria. Based on the construction of the Vulnerability and Health Conditions Index (IVCS), with socioeconomic and health variables of Brazilian municipalities at two points in time, prior to the implementation of the PMM in 2012 and later in 2015, we proceeded with the allocation of physicians considering the proposed indicator. The results showed that the PMM contributed to reduce regional inequalities in the availability of physicians by allocating them to municipalities with severe and high vulnerability in the small-scale IVCS and those located in the North and Northeast regions of the country. This set of municipalities were the neediest and, therefore, were prioritized. However, the evidence also pointed to failures in the allocative process and a decrease in the regular supply of physicians. Finally, the last study analyzed the effects of PMM from quasi-experimental studies on some health indicators of municipalities in situations of high and severe vulnerability, considering the IVCS of the year 2012. The findings allowed to point out significant increases in statistical terms of 0.49 pp in the rate of physicians in PHC, expansion of the population coverage of the family health teams (eSF) of 25.61 points, in addition to the expansion of medical visits in 33.49 points. However, these advances related to the expansion of access and coverage did not translate into an increase in the number of people enrolled in the eSF, the resolution of PHC, and the reduction of infant mortality. This indicates difficulties in reducing regional inequalities in health. The short-term results do not point to improvements in hospitalization and infant mortality indicators after the insertion of the PMM, but rather to strengthen the provision of health services in PHC by improving the access, coverage and distribution of physicians in the national territory, what advances to make it more equitable are needed. Given the favorable results, it is possible to see, or at least, the conditions for the PMM's advances in the medium and long term in public health. Keywords: Institutional Arrangements. State Capacities. Primary Health Care. Human Resources in Health. More Doctors Program