Public-Private Partnerships in the Brazilian Health Sector
Autor: Fernanda Palermo | Publicado: 2015-06-23T15:59:00-03:00


Project Regarding Public-Private
Partnerships in the Brazilian Health Sector



Fernanda Kellner de
Oliveira Palermo

Public Policies
Researcher



Summary



Due to recurring problems in the delivery of services
in health care, either public or private, and to prevent these systems from
collapsing in the near future, this project’s main goal is to propose to the general
public the extinction of operators of health insurance, whose commitment is
solely on profit, by replacing them by medical societies fundamentally based on
professional ethics, which will be able to form associations to act as private
partners in contracts of public-private partnerships in the public health
sector. In these contracts, the ones who become insured will be shareholders of
funds through securitization models. 



The general public is
kindly requested to post opinions, contributions, considerations and criticisms
after reading the following explanations: 



1. Current scenario
and example of implementation



Brazilian Federal Law No. 11,709/2004, Lei de Parcerias Público-Privadas&nbsp;<!--[if !supportFootnotes]-->[1]<!--[endif]-->, establishes general principles, rules and procedures
to streamline public procurement and government contracts based on PPPs. These
general rules are binding to the federal, state, federal district and local
levels. Since 2004, this instrument has been applied to several areas where
public services are delivered, including healthcare. &nbsp;&nbsp;

After many
years of enactment of the statute and due to the analysis of a sample
implementation in the area of health, it is possible to point out its advantages,
which are analyzed by Tomas Anker and Bruno Ramos Pereira<!--[if !supportFootnotes]-->[2]<!--[endif]-->
as follows:



·&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; The
"packaging of services" (or bundling) centers under the leadership
of a single service provider responsible for the delivery of various scopes
necessary for the supply of a given good or service;

·&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; The
establishment of performance indicators output-based, i.e. based on
goals and results;

·&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Greater
longevity of PPP vis-à-vis a traditional contract;

·&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; The
private partner cannot by contract invoke the need for more financial resources
for alleged extra costs or even claim the need for further term;

·&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Attractiveness
of other segments of the economy that traditionally do not have interest in
other contracts of public administration;

·&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; The
tonic of a PPP contract is to allocate the risk to the partner who can best
manage it;

·&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; The
adoption of information systems may be required. It may create greater richness
of analysis, including more accuracy in operating costs;

·&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; PPP
enables maintenance, conservation and renovation of the technological park of
clinical equipment within a single contract.





The
authors mentioned above<!--[if !supportFootnotes]-->[3]<!--[endif]-->
bring up an example of implementation of a PPP contract in health area,
pointing out that the "Suburb Hospital, whose contract is already signed and
in full implementation was the first PPP in Brazil's health system within the
Federal Law No. 11,079/04, the Federal law of PPPs". 





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(Suburb
Hospital in Salvador - Bahia n.d.)<!--[if !supportFootnotes]-->[4]<!--[endif]-->



Owing to
this important milestone in the State of Bahia and because it is a successful
example, it is relevant to refer to some features of its implementation explained
by José Fucs<!--[if !supportFootnotes]-->[5]<!--[endif]-->:



·&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Challenge:
open a new public hospital, with quality services and low investment from the government;

·&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Solution:
grant to private initiative the administration, operation and hospital
equipment;

·&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Result:
good standard of assistance to the population and cost 10% less than other
public hospitals to the State.

&nbsp; 

&nbsp;&nbsp;

2. Restructuring the
provision of healthcare services in Brazil 



The
current project aims at presenting stages of implementation for a new modeling
regarding the provision of healthcare services in Brazil. Based on the
classification presented by Tomas Anker and Bruno Ramos Pereira<!--[if !supportFootnotes]-->[6]<!--[endif]-->,
it is possible to outline public-private partnership contracts whose
contractors belong to three sectors of activity: public sector, private sector
and philanthropic entities. Accordingly, the extinction of the health plan
operator whose motivation is based strictly on obtaining profit occurs. The
authors present three forms of PPP development in the area of health, in
verbis:



·&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; PPP
can be developed within a less interventionist manner: only non-clinical
activities are transferred, such as hospitality services and the construction,
acquisition and maintenance of hospital infrastructure;

·&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Intermediate
manner: one can also think about transferring logistics of medicines and
materials, significant portions of the provision of services;

·&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Those
who desire a more integral transformation can think of complete PPP contracts: clinical
activities in addition to supporting activities are transferred (“bata-blanca”
project). 





By
updating data of the National Register of Health Establishments (CNES), which
releases the current infrastructure and operating conditions of the medical
institutions in all spheres, it is possible to carry out a nationwide public
policy for the promotion of public-private partnerships in healthcare according
to the successful case implemented in the Suburb Hospital in the State of Bahia
in regions where public hospitals are indispensable. 

In regions
where the largest portions of the population with sufficient income to afford
health insurance costs are concentrated, it is necessary to gradually implement
PPP contracts in which the service users have the possibility of becoming
shareholders of investment funds created by financial institutions. Such an
arrangement arises from an under-financed system, generated by the inefficiency
of its management. This specific issue is analyzed by Rafael Andreazza Daros<!--[if !supportFootnotes]-->[7]<!--[endif]-->,
who points out the following remarks regarding the Brazilian Unified Health
System (SUS):



The way
the system is financed impoverishes precisely those whom it seeks to help and
brings down the quality of the service, once the money available for each
treatment becomes scarcer each time a patient is taken care of. Even worse,
regulations to prevent the exodus of doctors to the private system hinder
competition and make treatments more expensive. 

Another
harmful effect of all that paternalism is the destruction of the stimulus to
charity, sense of citizenship and responsibility of citizens. 





Through a
system in which users are encouraged to contribute with accessible cost, as
well as the possibility of monitoring, controlling and participating in
management, it becomes possible to keep establishments managed by medical
societies with the support of philanthropic entities, in public-private
partnership contracts structured in accordance with the aforementioned
classification. Due to the transfer of public assets to these establishments,
they must provide medical assistance services to low income population, in
cooperation with the network of existing public establishments in the locality.


Every
medical institution of the country should stimulate the use of the National
Health Card for an adequate monitoring system. The goal is to extend this card to
users of health plans so that the system can identify the status of each
patient, with a view to efficiency related to the compensation for private
institutions with regard to services provided to the public health system
users. It is possible to create a health system in which healthy practices and
health campaigns are encouraged, if the population becomes aware of the costs
of the services provided and has the option to become user of affordable health
plans, enabling the targeting of public investment in health care to regions of
the country in which it is indispensable. 

In case it
is possible to overcome the challenges represented by pressing issues such as
the obstacle of double taxation and the possibility to confer tax immunity to
charities in the context of PPPs, there will be mechanisms to target the long-term
achievement of an efficient system of universal health care, whose model can be
applied in other countries or development contexts. Moreover, risk allocation
will be better targeted after the analysis of the achievements during the
contract’s life-cycle. 








<!--[if !supportFootnotes]-->

<!--[endif]-->




<!--[if !supportFootnotes]-->[1]<!--[endif]--> &nbsp;&nbsp;Lei
No. 11.079, de 30 de dezembro de 2004, D.O.U. 31.12.2004 (Brazil).



<!--[if !supportFootnotes]-->[2]<!--[endif]--> &nbsp;&nbsp;Tomas Anker &amp; Bruno Ramos Pereira, O atual cenário das PPPs no setor de saúde pública no Brasil:
potencialidades, desafios e as primeiras experiências em âmbito estadual [The
current scenario of PPPs in the public health sector in Brazil: opportunities,
challenges and early experiences statewide], in Parcerias
público-privadas: experiências, desafios e propostas[Public-private partnerships: experiences, challenges and
proposals] 163 (LTC eds. 2013)(author’s translation) passim.



<!--[if !supportFootnotes]-->[3]<!--[endif]--> &nbsp;&nbsp;&nbsp;Id. at 174 (author’s translation). 



<!--[if !supportFootnotes]-->[4]<!--[endif]-->&nbsp;
&nbsp;Suburb Hospital in Salvador-Bahia, n.d. photograph, viewed Jun. 18,
2015&nbsp;http://www.desenbahia.ba.gov.br/Noticias_Ultimas_Noticias_02.aspx?id=2218.



<!--[if !supportFootnotes]-->[5]<!--[endif]--> &nbsp;&nbsp;&nbsp;José Fucs, Em Salvador, um hospital público que parece
privado [In Salvador, a public hospital that looks like a private one], available at
http://epoca.globo.com/tempo/noticia/2014/04/em-salvador-um-bhospital-publicob-que-parece-privado.html
(last visited Jun. 20, 2015) (author’s translation). 



<!--[if !supportFootnotes]-->[6]<!--[endif]--> Anker &amp; Pereira, supra note 2, at 168 (author’s
translation).





<!--[if !supportFootnotes]-->[7]<!--[endif]--> &nbsp;&nbsp;Rafael Andreazza
Daros, Como o SUS está destruindo a saúde
dos brasileiros [Ways that SUS is using to destroy Brazilians’ health], available at
http://www.mises.org.br/Article.aspx?id=1849 (last visited Jun. 21, 2015)
(author’s translation).