2005年-世界发展银行全球_The_Political_Economy_of_Health_Services_Provision_and_Access_in_Brazil_44页_569kb

Summary of WPS3508: The Political Economy of Health Services Provision and Access in Brazil

Core Content

This paper explores the political economy of health services provision and access in Brazil, focusing on the Unified and Decentralized Healthcare System (SUS). It examines how local politics, government structure, and decentralization influence the availability and accessibility of public health services, particularly for the uninsured population.

Main Questions and Findings

The study addresses two key questions:

1. How do politics and government structure affect the distribution of public health services (doctors, nurses, and clinics) across counties?
2. How do politics and decentralization influence the probability that the uninsured receive health care when they need it?

Key Findings:

• Higher per capita levels of SUS doctors, nurses, and clinics increase the probability that the uninsured receive medical attention.
• Counties with popular local leaders and political alignment between the county mayor and state governor have higher levels of health service provision.
• Political participation, income inequality, and the percentage of votes for leftist candidates are positively correlated with health service provision.
• Administrative decentralization of health services can reduce provision levels unless it is accompanied by good local governance.
• Counties with full authority over health care provision and a governance plan provide more health services per capita than decentralized counties without such plans.
• Decentralized counties experience larger increases in health budgets following local elections compared to state-run counterparts.
• The probability of receiving medical attention is not higher in counties with full control over health care resources than in those with partial control, unless the county has a governance plan.

Theoretical Framework

The authors use a probabilistic voting model to analyze how political competition and voter preferences influence public health care provision. According to the model:

• Public health care provision increases with average income due to higher tax revenues.
• Uninsured individuals benefit more from public health services than the insured, implying that counties with a higher proportion of uninsured people may have higher levels of public health care.
• Political power and connections of local officials can increase public health care provision.
• Voter turnout among the poor/uninsured also affects the likelihood of receiving public health services.
• Decentralization alone does not guarantee better health service provision, but when paired with good governance, it can lead to better outcomes.

Health Care System Structure in Brazil

• Ownership and Administration:

  • While the SUS is publicly financed, many health facilities are privately owned.
  • County governments administer the system, with varying levels of authority:
    • Full State Management: State governs all aspects.
    • Basic Assistance Management: County manages basic care, state manages complex care.
    • Full County System Management: County manages both basic and complex care.
  • In 1999, 80% of counties had Basic Assistance Management, and 8% had Full County Management.

• Financing:

  • 70% of health services are funded through federal transfers, which are split into:
    • Fixed transfers: Based on population.
    • Variable transfers: Tailored to the poor, often requiring co-financing.
  • Complex care is funded through specific transfers and is subject to fee-for-service schedules and annual ceilings.
  • County and state governments may supplement federal transfers with their own revenues.

Empirical Analysis

• Health Inputs and Access:

  • The probability of an uninsured individual receiving health care is positively associated with the number of public health inputs (doctors, nurses, clinics).
  • Geographic distribution of health services and efficiency of management are important in determining access.
  • The authors use the 1998 PNAD survey to analyze access, focusing on individuals who did not have private health insurance and reported needing medical attention.

• Variables Considered:

  • Public health inputs (doctors, nurses, clinics).
  • Private health inputs (doctors, nurses, clinics).
  • Demographic variables (age, sex, household size, education, race).
  • Illness severity (number of days unable to function due to illness).
  • Interaction terms for child-specific illnesses (e.g., diarrhea, respiratory disease).
  • Political variables (local leadership, political alignment, political participation, leftist votes).

Conclusion

The paper concludes that:

• Decentralization can improve health service provision if accompanied by good governance.
• Political factors such as leadership, alignment, and voter participation significantly affect the level and accessibility of public health services.
• Democracy and political engagement can lead to better public service delivery, but only if local officials have the capacity to govern effectively.

The study contributes to the literature on democracy and economic performance, as well as decentralization and public service provision, by showing the interplay between governance, political structure, and health outcomes.