Cohn A, Elías MP. Equidade e reformas na saúde nos anos 90. [Equity and health reforms during the years of the 1990s.] Cuadernos de Saúde Pública [Public Health Notebooks] (Rio de Janeiro, Brazil) 2002; 18 (Supl.): 173-180.
Objectives: To analyze the Brazilian Public Health Reform from the perspective of social inclusion and exclusion, and to analyze an experience of integration between the public and private sectors in the Hospital Clinics of the Faculty of Medicine, University of Sao Paulo.
Methodology: Analytical and interpretive.
Results: The authors consider that the academic attention paid to the Brazilian Reform demonstrates a relative disinterest in the political articulation between health and democracy as well as a relative void regarding questions related to decentralization, reform of the State, and health policies. The authors hypothesis is that this situation is due to the relative weakening of Public Health Reform proposals, incorporated into the Constitution of 1988. Since the mid-1990s, one observes an emphasis on pragmatic aspects of regulation and implementation of the Unified Health System, especially in technical dimensions (management, programming, and evaluation).
The article considers that it is necessary to rescue the political dimension, to depart from the matrix of poverty as natural, and to move on to the matrix of social inequality. From these positions the authors analyze the experience of the Hospital Clinics of the University of Sao Paulo, demonstrating how a double file that of the users of private plans and that of the users of the Unified Health System becomes reflected within the Hospital Clinics the existent discriminations of society.
The analysis of the experience at the Hospital Clinics shows that the linkage of state services with market initiatives carries with it an alteration of the relationship between the public and private sectors in the production of services. The authors emphasize management modalities, an introduction of market mechanisms, and by establishing a link between payments and performance a detrimental effect in the wider question of social inclusion or exclusion, ruled by the dimension of citizenship and the autonomy of social subjects.
Conclusions: The conceptual bases utilized and the experience analyzed show the necessity of establishing a social and political discussion about the new modalities of service provision. These modalities surpass the limits of health care access. The authors also analyze the dimension of reproducing social inequality in terms of social exclusion or inclusion in institutional practices and service delivery.
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