Regional governance: strategies and disputes in health region management

OBJECTIVE To analyze the regional governance of the health systemin relation to management strategies and disputes. METHODOLOGICAL PROCEDURES A qualitative study with health managers from 19 municipalities in the health region of Bahia, Northeastern Brazil. Data were drawn from 17 semi-structured interviews of state, regional, and municipal health policymakers and managers; a focus group; observations of the regional interagency committee; and documents in 2012. The political-institutional and the organizational components were analyzed in the light of dialectical hermeneutics. RESULTS The regional interagency committee is the chief regional governance strategy/component and functions as a strategic tool for strengthening governance. It brings together a diversity of members responsible for decision making in the healthcare territories, who need to negotiate the allocation of funding and the distribution of facilities for common use in the region. The high turnover of health secretaries, their lack of autonomy from the local executive decisions, inadequate technical training to exercise their function, and the influence of party politics on decision making stand as obstacles to the regional interagency committee’s permeability to social demands. Funding is insufficient to enable the fulfillment of the officially integrated agreed-upon program or to boost public supply by the system, requiring that public managers procure services from the private market at values higher than the national health service price schedule (Brazilian Unified Health System Table). The study determined that “facilitators” under contract to health departments accelerated access to specialized (diagnostic, therapeutic and/or surgical) services in other municipalities by direct payment to physicians for procedure costs already covered by the Brazilian Unified Health System. CONCLUSIONS The characteristics identified a regionalized system with a conflictive pattern of governance and intermediate institutionalism. The regional interagency committee’s managerial routine needs to incorporate more democratic devices for connecting with educational institutions, devices that are more permeable to social demands relating to regional policy making

Proposição de um índice do enfrentamento governamental à violência intrafamiliar contra crianças e adolescentes

O artigo apresenta o processo de construção do Índice de Enfrentamento de Violência Intrafamiliar (IEVI), cujo objetivo é avaliar estratégias da gestão municipal em face dessa violação de direitos infantojuvenis. Sua formulação envolveu análise preliminar de indicadores de estudos anteriores e técnica grupo nominal com especialistas. Foram selecionados quatro indicadores: existência de Plano Municipal de Enfrentamento das Violências contra Crianças e Adolescentes; existência de fluxo intersetorial para atendimento e acompanhamento de crianças e adolescentes em situação de violência intrafamiliar e suas famílias; taxa de Conselhos Tutelares por habitantes do município; e existência, nas redes municipais de educação, assistência social e saúde, de instrumentos padronizados para notificação/comunicação das situações de violência contra crianças e adolescentes. Com base em banco de dados de estudo anterior, foi realizado o exercício de aplicação em quatro capitais brasileiras. O IEVI constitui uma ferramenta para monitorar e mobilizar esforços para a implantação de ações de enfrentamento da violência