Modelos de cofinanciamento federal e a função política na indução do desenho assistencial da Atenção Primária à Saúde do Sistema Único de Saúde

Abstract

The study aims to analyze the federal co-financing models of Primary Health Care of the Unified Health System as a political tool to induce the care model, focusing on the analysis of the interfederative relationship. The chosen methodology was documentary analysis, and the SUS PHC regulations published by the Ministry of Health between 2016 and 2024 were selected from the point of view of the relationship between the care design and the federal co-financing model. Historically, the financing of public health policies and financial transfers from the Union to subnational spheres have been an important mechanism to induce, shape and regulate the policies implemented by state and municipal governments, ensuring federal coordination of health policies. The Brazilian process of decentralization in health has a political-administrative character and produced important effects in increasing the coverage of the Family Health Strategy in the territories. However, federal coordination maintained the concentration of power to induce public health policies through conditionalities linked to fund-to-fund financial transfer mechanisms. This model, over the more than three decades of SUS, has had repercussions on interfederative relations. While the decentralization guideline for the progressive health field is related to democratization, for the conservative field it is related to greater power for municipalities and decision-making autonomy for local managers, reconcentrating power in the local political elites. The scenario of interfederative relations was the basis for analyzing the three models of federal co-financing and the care model induced in each period, considering: Basic Care Floor - PAB (1996-2019), Previne Brasil Program (2019-2024) and new federal co-financing methodology for SUS PHC (2024-current). Thus, it is understood that the first model was essential for the expansion of Family Health teams in the country and was composed of several rules to be followed so that municipalities could access resources, generating criticism about the centralization of federal management. The Previne Brasil Program model subverted principles that guaranteed comprehensive PHC and comprehensive care, to the detriment of fostering managerial autonomy at the municipal level, altering the pillars of federal coordination present in co-financing, in order to induce a focused care model that diverges from the principles of universality and comprehensiveness. The third model revisits the principles of the SUS and the Constitution and advances some debates based on a movement to recentralize care induction through federal financial induction. Thus, the constant tension between local and central power reverberates in the effects of the policy and in the paths of PHC induced.