O público e o privado na saúde do Estado do Rio de Janeiro: o caso da transição do modelo da gestão de serviços de saúde

Abstract

This thesis aims to perform a detailed analysis of the process of inclusion of the topic of private management of public health services in the decision-making agenda of the State of Rio de Janeiro and its subsequent approval and implementation. To understand this process, we propose a dialogue between paradigms and disciplinary matrices, incorporating and articulating visions of completely different theoretical status. To do this, we seek models of public policy analysis that explain processes at the local level, but without abandoning the theoretical perspective that guides what issues will be posed and what kind of research will be carried out. The hypothesis developed is that Governor Sérgio Cabral and his Secretary of Health, Sergio Cortes, undertook this change taking advantage of a favorable moment for negotiation with other participants in the state political arena, a moment caused by the mutiny of the military firefighters. This would have allowed the health management theme to enter the government's agenda - a problem largely built with the help of the media - and later, for private management of public services to be presented as a solution. An epistemic community centered on the World Bank constructed such a thesis and that contrasts with the one previously held in Brazil, defended by the Sanitary Reform. The results showed that the Governor and the Secretary placed the problem of health management in the state of Rio de Janeiro on the public agenda based on a sequence of re-elaborations of the management of services as a public health problem. First, it was elaborated as a problem of deficiency in the health care network, mainly of emergencies and, later on, rearticulated as a result of the inability of the direct administration in the provision of services and control of human resources. Data on mass media production in the period, for their part, show that communication vehicles were crucial to building the problem by developing an image of public health services as being in a "critical" or "emergency" state. Regarding the negotiation in the three arenas that could act as veto points for the change, the results showed that the small bureaucratic capacity of the State Department of Health, the small capacity for social control of the State Health Council and the abundance of resources to make parallel payments to ALERJ deputies reduced negotiation costs sufficiently to permit the approval of the transition to private management of public services through Social Health Organizations.