Recife: technique and policy for better health services – 07/04/2023 – Saúde em Público

In the book The Equilibrist Democracy, Gabriela Lotta and Pedro Abramovay analyze a set of reforms designed and implemented by the federal government between 2002 and 2016 to understand what can determine the effectiveness of public policies in Brazil. The book’s thesis is clear: the State is more capable of providing answers that are worthy of its citizens when the process of formulating public initiatives manages to balance itself between dimensions that are sometimes in tension. First, politics, represented here by the contradictions between the interests of a diverse set of political actors and civil society. Second, the technique, represented by scientific evidence and the ability of bureaucracies to expand their ability to provide programs and services to the population.

Since 2021, IEPS and Umane have been working together with Recife City Hall in the Program Qualifies Primary Care to design and implement policies that improve the quality of health services. Within the program’s fronts is Recife Monitora, a policy that uses result indicators, work processes and the perspective of users of the Unified Health System (SUS) to assess the quality of primary care services, conditioning incentives monetary contributions to professionals from the municipal health network to the results achieved. The construction of this policy together with the City Hall of Recife shows us the importance of this subtle balance between technique and politics, so well described by the authors of The Equilibrist Democracy.

Recife monitors

Every resident of the city of Recife who goes to a Basic Health Unit (BHU) for prenatal care, or any other Primary Care service, receives a message from Whatsapp, requesting an evaluation of your service. There is also the possibility of making complaints and suggestions about the quality of care and the functioning of the health network as a whole in its territory. These assessments, in turn, in addition to serving as a strategic input for local management, are used to determine the payment for performance of doctors, male and female nurses and other health professionals involved in care.

Since December, the platform has had more than 20,000 responses, equivalent to more than 1% of Recife’s population. The experience of this collaboration teaches us about the subtle balance between technical and political dimensions for obtaining results within governments.

The Technique

Recife Monitora combines a set of mechanisms that have long been studied in the public policy literature. First, it creates incentives, both monetary, such as direct payment to health professionals, and non-monetary, such as publicizing the population’s opinions about the quality of care. Second, use frameworks public health standards developed to determine and measure the quality of health services.

Third, it resorts to a trend, increasingly prevalent in the world’s most advanced health systems, of bringing men and women closer to the process of designing, implementing and evaluating public policies. A trend that encourages the co-creation between end users and health professionals of the best possible experience of health services. From a theoretical point of view, the creation of incentives, the precise measurement of the quality of services and the patient’s involvement in the production of policies are all mechanisms that lead to the improvement of public services.

It is important to emphasize that this initiative, by itself, would not be feasible nor sufficient to induce an improvement in health services. Over these two years, Recife City Hall has sought to recompose the health teams that were incomplete and is currently creating a new set of leaders directly responsible for improving processes and results in each basic health unit. In addition, the City Hall has Territory Support, qualified professionals who serve as a link between management and the frontline in the implementation of policies.

The politics

In addition to technique, politics was and is also present throughout the process of designing and implementing Recife Monitora. All stages of the project were built with the radical involvement of health, assistance and management professionals, there was mobilization of different instances of the City Hall in decision-making on the initiative and also a joint work with the mayor’s office to institutionalize the policy .

Before Recife Monitora even started, we held more than 12 workshops, consulting from Community Agents to the Secretary of Health, from family doctors to supporters in the territory. In total, more than 200 people were interviewed at this stage. Then, a working group was created along with several members of the network to design the indicators that would be measured in all the project instruments.

The implementation of the project only took place after lengthy negotiations with the professional associations to which health professionals in the Recife network are linked. This process allowed Recife City Hall to arrive at a final tool that was both technically correct and politically viable. With a more mature design at the technical and political levels, the program was institutionalized through a municipal law, presented to the Chamber of Councilors by the City Hall and enacted last December.

The Recife Monitora experience reinforces the argument of the authors of “A Democracia Equilibrista”: without a delicate seam between technique and politics, Brazilian cities will not advance in facing their main challenges. Between technique and politics, we need to choose both, aware that making public policies is always a process of discovery.

Arthur Aguillar is Director of Public Policy at the Institute for Health Policy Studies (IEPS). Miguel Lago is Executive Director of the Institute of Studies for Health Policies (IEPS).

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