Avaliação de impacto do "Pacto pela saúde" sobre indicadores de eficiência e de vulnerabilidade de saúde municipais (2006-2013)

Abstract

This study aims at evaluating the impact of the "Pacto pela Saúde" program on health policy performance, in terms of efficiency and outcome, of Brazilian municipalities from 2006 to 2013. “Pacto pela Saúde” is the Operational Standard in force by the Brazilian Unified Health System (SUS) of Brazil (Ordinance MS n. 399/2006). This Program had as one of its main guidelines the improvement of health policy governance by the federated entities, with special attention to results management, materialized in the signing of the Management Commitment Term (MCT). This management policy was in force from 2006 to 2012, receiving the signature of 4,561 municipalities, representing 82% of the total Brazilian municipalities. In this way, the present thesis answered two questions: i) did the time of adhesion of the municipality to the program increase the efficiency levels of the Primary Care policies?; ii) has the improved efficiency provided by adherence to the "Pacto pela Saúde" reduced the health vulnerability between the participating municipalities? In response to these two questions, two empirical exercises were performed. First, the causal effect of the municipality's participation time in the program on an efficiency indicator of the primary health care policy was estimated using a Generalized Propensity Dose-Response Model (LECHNER, 1999; IMBENS, 2000). Second, the causal effect of the municipality's participation in the program on an indicator of municipal health vulnerability was estimated using the structural causal model proposed by Pearl (2000). The indicators of efficiency (IDEAB) and health vulnerability (IVS) were calculated using a multivariate Principal Component Analysis technique using specific information to the Primary health care model provided by the Ministry of Health. This research presents three contributions to the current literature. First, it analyzes in a pioneering and rigorous way the causal impact of the "Pacto pela Saúde" program. Second, it provides substantive evidence on how municipal health production responds to this policy. Third, it calculates specific municipal efficiency and vulnerability indicators for Primary Care. The main results of this thesis were: i) it was evidenced that the greatest time of adhesion to the Program occurred in municipalities with better health conditions and, therefore, more favorable to reach the agreed goals; ii) there is a positive correlation between time of adherence to the Program (dose) and efficiency indicator (IDEAB). The municipalities that acceded to the Program presented IDEAB higher, compared to the municipalities that did not adhere. In general, smaller municipalities (up to 10 thousand inhabitants) obtained better IDEAB's than larger municipalities; iii) There is a negative correlation between IDEAB and IVS; iv) a positive and significant impact of the Pacto pela Saúde on the efficiency indicator was estimated; v) positive and significant impact of the management efficiency provided by Pacto pela Saúde on the reduction of health vulnerability indicator of municipalities; vi) adequacy of the structural causal model and Pearl's (2000) back-door criterion of causal identification in the calculation of the effect of the Program on IVS