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(2) 70. (212). 第 10巻 第 2 号 (2005 年 8 月 ). 横浜国際社会科学研究. A@liberal@soci8@policy@stems@from@individu3@freedom,@equ3@opportunities,@and@non-government@intervention ， It@has@been@difficu. ぬldersen. (1990). for@liberalist@reformers@to@imp. Ⅰ. Ⅰ. ment@th@@ market@based@po. cy@into@ state@poli y ， Esping-. Ⅰ. s ぬ tes. Barg3ned@or@contracted@p. Ⅱ. guaranteed@to@prev3l@m3n. vate@we. Ⅰ. are@wil@logica. among@the@more@priV. Ⅰ. Ⅰ. y@rep. Ⅰ. cate@market@inequaliies,@but@is@a. Ⅰ. Ⅱ. o. ged@strata@in@the@ bor@forcC@ @@will@cert@n not Ⅰ. address》he『e are］eeds｛f》he［ost｝reca ouSy｝ ced『orkers・ ， 64) Ⅰ. Ⅰ. Ⅰ. Ⅰ. ・. The@outcomes@of@most@liber3@ regimes@have@resu ed@in@a@combination@of@individu8@ se -responSbiliy@and du3i m These@outcomes@inCude@one@group@which@depends@on@the@we are@system,@a@middle@Cass@which Ⅰ. Ⅰ. Ⅰ. ・. depends@on@soCal@insurance,@and@a@privieged@group@with@p. Ⅱ. vate@insurance ， This@type@of@. Ⅰ. ve@and@corporatist@we. Ⅰ. beralist@regime. ， 1990). includes@the@United@States@and@British@welfare@systems@(Esping-Andersen The@conserva. Ⅰ. are@state@focuses@on@class@and@status:@Aust. Ⅱ. a,@ France,@. Germany@and. It3y@are@examples@of@this@modC THe@important@aspect@of@the@conservative@modC@ is@to@protect@the@status@and Cass@as@wCl@as@defend@soC8@ rights Contrary@to@liber@@ soC3@ policy,@the@conservaLve@poli y@dev3ues@the@market ・. ・. mechanism@of@the@provision@of@welfare@. services@ (Esping-Andersen. ， 1990). ・. Another@characteristic@of@the. corporatist@modC@@@that@this@regime@has@usu3 Y@been@formed@by@the@Church@whi h@values@the@preservation@of@the Ⅰ. famiy ， The@corporaLst@modC@. 8lows@the@government@to@intervene@in@famiy@matters@du. family@members@are@deemed@incompetent. Ⅱ. ng@the@period@when. ， The“overnment（s》he〕ast〉esort’or《eeking》he『eare｝rovi ions Ⅰ. in@the@corporatst@regime. Corporatism@had@a@strong@baSs@in@the@European@nations@not@only@because@of@tradition3@ mechani ms@such@as ℡ al@guilds， but@because@of@the@preservation@of@both@hierarchy@and@privilege. commer. ， Most@of@all， the@Catholic. Church@has@played@an@important@role@in@shaping@all@social@reform. Scandinavian@countries@are@pioneers@of@soci3ist@soC3@ poli y In@th@@type@of@regime,@soC3@ rights@become uni ers8i Ⅰ c@and@"de-commodified"@even@for@midd Cass@ci zens@(Esping-Andersen,@1990) ， The@go8@ of@a@soC8 ・. Ⅰ. Ⅰ. democra. Ⅰ. c@regime@ @@ to@ achieve@ equal@provi. univers3istic@insurance@system soC3im We. Ⅰ. ， The@socia. ions@of@high@ qua. st@model@@@ we. Ⅰ. ． "@ Esping-Andersen@menLons@that@not@8l@we. Ⅰ. Ⅰ. ty@welfare@for@a. ciizens@based@on@. Ⅰ. characterized@as@the@"fusion@of@. Ⅰ. are@states@are@di hotomied@into@th@@. are@policies@in@some@countⅡ es@might@be@a@combinaton@of@both@liber3@. Ⅰ. one. berali m@and. exact@Cassifica Ⅰ on. and@soC8@ democraLc@characteristics. Since@soCal@structure@has@changed@over@time,@soCalists@WCre@forced@to@inCude@the@middle@Cass@into@their universali tic@welfare@state Theヾwedi socialist‥emocra the｝ioneer〉egarding》he「niversalism｛f h. Ⅰ. c . middle@class@standards. As@such,@corporatist@po. Ⅰ. cy@has@diferen. a. Ⅰ. Ⅰ. for@soCal@insurance@and@its@various@benefits@depend@on@the. ， liberal@policy@is@well@described@as@"welfare@states ， residualism" occupational@and@status@base ， On@the@other@hand. and@private-sector@weare Ⅰ. benefits@(Esping-Andersen. SoC3ist@poli y@is@idenⅠ fied@as@uni ersali m@and@has@the@least@differenals@of@the@soC8 Ⅰ. ・. ， 1990) 3. New￣ublic｀anagement‖nd？ealth￣olicy. As@a@liberalist@model,@New@Publ@@ Management@ management@during@the@1990's. ・. NPM@@@. deregulations@based@on@the@manageF8@ Eng. Ⅰ. nd,@Australia,@and@New@Zea. Ⅰ. Ⅰ. r@an3ySs@in@publi. publ@@ management@characterized@as@privatiza on,@contrac ng@out,@and form Especia y,@in@devCoped@countries@such@as@the@Unied@States, Ⅰ. Ⅰ. Ⅰ. ・. nd,@the@NPM@has@been@appli. organizations@and@agenCes@have@focused@on@imp McCourt・. (NPM)@ served@as@the@most@popu. Ⅰ. d@in@publ@@ management. menti g@the@NPM@program@@@. ・. Internation8@ aid. devCoPng@countries. examined》he‘ffecLveness｛f¨PM［ethods｛n《erVce‥every（n‥eveloping…ountries Ⅰ.
(3) ⅢleWe He@conCudes@that@there@@@. a@prob. Ⅱ荻. m@of@imp. Ⅰ. (K ㌶umiN0guch. eS ぬtemdHeaIthPoIicy. Ⅰ. menta. (213). け. on,@especi8ly@in@contractng@out. Ⅰ. there@are@non-NPM@methods@that@have@brought@the@success@of@the@implementati countries@such@as@BraZl@and@South@Africa. 71. Moreover,@he@argues@that. ・. n@of@programs@@@ devCopi. g. ，. 4@ The@Health@Care@System@in@Brazil There@are@three@m3or@ Ⅰ ers@of@heah@care@administration@in@Brazi;@Mini try@of@Health@located@in@Brasia,@a special@district@of@Brazil ， the@State@Secretary@of@Health@in@each@state@and@the@Municipal@Secretary@of@Health@in@each Ⅰ. Ⅰ. muni. i ality. The’in3 path》o》he…urrent”ea h…are｝rogram『as］ot‘asy’or》his…ountry》o‖chi ve‖nd］eeds》o｜e Ⅰ. described@before@exp. ining@the@depth@of@the@current@hea. Ⅰ. Ⅰ. h@care@system ．. In@the@authoritarian@era@from@1964@to. 1985.@a@highly@speciali ed@bureaucracy@dominated@control@of@various@policies@including@economic@and@even@health care@policies ， A@highly@centralized@system@of@soC3@ poli y,@par@culay@at@the@feder8@ vC,@resu ed@in@economi growth@and@the@strength@of@the@private@sector@and@broadened@the@hea h@care@system@as@we However,@thi Ⅱ. Ⅰ. Ⅰ. Ⅰ・. Ⅰ. economic@power@which@faded@away@drastically@by@the@end@of@the@1960 ， s ， resulting@in@the@economic@cLsis@of@the 1970's@whi h@grea y@affected@the@soCal@fabric@of@BraZl Essent@ lly,@the@debt@cris@@@@ the@1980's@put@immeasurably@negative@effects@on@the@private@sector,@i clu4ng Ⅰ. va. ous@state@. Ⅱ. ・. stitutions,@whih@ended@up@wih@privati. Ⅰ. ati n@as@the@structur8@a4ustment. regime@during@th@@. pe. od@gradualy@lost@3l@of@abiiy@to@solve@th@@. government@was@di. trusted@by@cii ens,@@@ was@pressured@by@CVl@and@soCal@organi. Ⅱ. finanC8@ criSs. ・. ， In@fact,@the@miliary. Since@th@@ authoria a. Ⅰ. Ⅱ. ons,@whi h@eventu8. an Ⅰ. 8lowed@them@to@form@the@baSs@of@the@public,@uni ersal,@and@democratc@hea h@care@system SoC3@ organi atons Ⅰ. and@civ@@ soCe bureaucracy. Ⅰ. es@put@forward@this@hea. Ⅰ. ・. h@care@initia ve,@which@was@par Ⅰ. Ⅰ. y@accepted@by@the@hea. h@care. Ⅰ. ・. Lobato@and@Burlandy@(2000)@ propose@that@the@conservative@elites@put@themse es@in@a@situation@where@they had@no@choice@but@to@enact@hea h@care@measures However,@when@the@elected@government@fo owing@the Ⅰ. Ⅰ. Ⅰ. ・. dictatorship@took@power,@it@focused@on@ ber3i m@and@rCected@these@proposed@soci3@. programs. Ⅰ. 4.1@ Centralized@Health@ Care@ Administration Hea pⅡ. Ⅰ. h@care@po. vate@sectors. ・. Ⅰ. cy@was@organized@into@the@three@subsystemS@. soC3@ security,@the@Mini try@of@Hea h,@and Ⅰ. SoC@@ security@was@unified@in@the@1930's@when@the@state@j0ned@@@. the@finanCng@of@publ@@ and. pFvate@companies'@ soCal@security@benefits,@one@of@whi h@was@to@provide@hea h@care@for@both@workers@and Ⅰ. h@the@Instiuton@of@Retirement@and@PenSon@was@establi hed, dependents ， The@soCal@security@system,@in@whi became@the@dominant@provider@of@hea Bu. Ⅱ. Ⅰ. h@care@servi. es@for@the@exCuSve@BraZ. Ⅰ. an@populaton@. (Lobato@and. andy,2000) ．. The@Minitry@of@Hea. Ⅰ. h@was@organized@as@a@para el@structure,@8ong@with@soci3@ security,@and@focused@on Ⅰ. preventive@care@until@the@1950's. ・. Moreover,@@@ was@responSb. Ⅰ. for@the@management@of@over8l@faC. the@provision@of@serVces@by@physi third@system ， the@private@sector@engaged@@@. Ⅰ. ties， In@the. i ns@through@direct@payment. ，. Under@the@military@regime@from@ 1964@to@ 1985.@the@central@government@intervened@in@a social@poliCes, espeCa y@concerning@health@care@pol y,@whi h@stimulated@the@private@sector@and@legitmized@the@government Ⅰ. Ⅰ. ise. Ⅰ・. Ⅰ. During@th@@ pe. Ⅰ. od,@hea h@care@coverage@increaSngly@became@univers8@ Ⅰ. assume@responsibility@for@servi e@provi i n@itse. Ⅰ・. 市 eIns 廿杣廿on0fRe. 廿. rementandPenslonwe. 72@enacted@on@November@21. 丘. as@the@government@started@to. Wih@th@@ trend@of@uniersali ati n,@the@various@organiations@of. eunl%edastheNa. 億. 0nalIns 億血teforSoclaISecu lゆ underDecree 丘. ， 1966.@ Under@this@unification ， people@in@the@formal@labor@market@were@exclusively.
(4) (214). 72. 第 10 巻第 2 号 (2005年 8 月 ). 横浜国際社会科学研究 Brazilian？ealth，areヾystem（n》he・，. Figure・ Central. Mlnls rv,,0. .yof Budge@. Government. Health. -- Publlchospl は. 廿. ほ. Budget. 凹口 Compulso 卍 c0n@nbU 百 On. General Un Ⅳ frs 辻y 及. General@ TaXa Ⅱ 0n. government. DRG-like@fee れ. ぬ "" 。。. non@pro [. Budget. He3th-SUS. Government@. &‖mbulatories. Taxation. Sは le ゐ l0cal. Brazilian？ealth，areヾystem（n》he・， s. Figure・. s. №cal. Ⅹ. 皿. Ⅰ. Se 丘下Ⅱ Ce. Public. d. hoSP@ ロ l. 丘. hospltal. sぬ te. General. Fee@for. Taxation@ government. 用b№ ambulator. Social《ecurity. Bud ミ el Contribut@. Private. hoSPl 臼尽. Social SeCU ㎡Ⅱ. D. he 田 th. Subsidies. Private. Ellle Per@capil eefor. v"olun pr p ⅢdⅤ. 中 lrises ゐ. 色. た. Se. イスⅡ CeS. ㎡. pr Fee@for@service pd He田山 告. e.e-pald/ffteefo Own《ervices Salaries. pservice. Ⅰ. reimbursement. て. Company. hospi 田sand. ・. て. 30%｝op. て. 甘 adeunlonS. Hospitals. ・. companies. POpula. Ⅱ. Private. 0n. hospi 臣尽. Ente 申 hses. ambulatories. S田 aneS. Fee’or. ニ. Se てⅤⅠ CeS. Private，li. Pa れ enlS Pre-paid｝lans. Population. Se@りⅡ CeS. Pa Ⅱ entS. Doctors Fi ancing@flow De. Ⅱ. ven,. 皿. Fee. Ente 中 rlses. イ. o. て. is. seM㌧Ⅱ CeS. FinanCng@flow. 0w. Delivery@flow. 舖 urce:l 刀 bato,L.(2㏄O ,P.117. 舖 u 「 ce: ぬ bato 几 (2 ㏄ 0),P.122 ・. covered@by@social@security,@however,@those@in@the@rur8@ areas@were@not@Cigib for@the@proviion@of@hea h@care Ⅰ. servi es,@which@demonstrates@that@hea (Lobato@and@Burlandy. Ⅰ. h@care@was@mostly@reserved@for@p. Ⅱ. Ⅰ. vieged@peop. Ⅰ. to@receive@in@Brazil. ， 2000). In@the@1970， s ， the@National@System@of@Social@Security@and@Social@Assistance@(SINPAS). ， which@was@responsible. for@soC3@ security@benefits,@and@then@Nation3@ Institute@of@Medi8@ Care@and@SoC8@ Security@ (INAMPS),@whi was@responSb. Ⅰ. for@medi 3@ were@created ， Medi. 3@. serVces@were@pro. by@the@private@sector ， The@health@centers,@publ@@hospita governments@provided@hea. Ⅰ. ded@not@only@by@the@publ@@sector@but@a o Ⅰ. and@pFmary@hea. Ⅰ. h@care@units@at@the@three@ve Ⅰ. Ⅰ. of. h@care@services@to@the@people ， The@private@servies@were@CasSfied@as. Independent｝rofesSonaor”ea. 1.. Ⅰ. Ⅴ. h. Ⅰ. Ⅰ. h《eitv@ ，. es…ontracted｜y（nd* idua. Ⅰ. or…ompani s‖nd’inanced. by@the@private@sector@itsCf ・. 2.@ Private@sector@contracts@in@whi h@profit@and@nonprofit@unis@provided@serVces@to@the@publ@@ sector under@contract@to@the@federal@government@(Lobato@and@Burlandy. ， p ， 84). Since@p vate@medical@serVces@were@p3d@by@each@service,@it@became@cost Y@and@onY@served@certain@regions@where Lobato@and@Burlandy@ (2000)@ argue@that@there@were@no@health@care the@affluent@populaton@was@concentrated Ⅱ. Ⅰ. Ⅰ. ・. policies@established@based@on@actual@health@needs@and@epidemiological@profiles. economi 3ly@vulnerab Ⅰ. peop. During@the@centr3ized@mi. ， which@led@to@the@exclusion@of@all. Ⅰ， Ⅰ. tary@regime,@there@was@an@increase@in@private@medi. al@servi es. ・. Since@social. security@coverage@was@extended@to@previouSy@uninsured@workers,@and@emergency@care@was@provided@for@t whole@popula. Ⅰ. on,@the@demand@throughout@the@health@care@system@increased,@and@INAMPS@contracted@to@the. private@sector In@th@@manner,@only@27@percent@of@a hospi8@ beds@were@publ@@ and@73@percent@were@in@the@private ・. Ⅰ.
(5) The@Welfare@State@and@Health@Policy@ (Kazumi@Noguchi). (215). 73. sector ， This@expansion@of@the@role@of@the@private@hospit3@ gitimized@the@exitence@of@the@mitary@government@and Ⅰ. Ⅰ. ， 2000). stimulated@the@private@sector@(Lobato@and@Burlandy. 4.2@ Health@ Care@ Reform It@is@important@to@note@that@there@was@such@a@great@struggle@for@BraZl@to@reach@the@imp mentation@of@the Ⅰ. universal@health@care@system@(SUS)@in@1988.@ The@Brazilian@reform@movement@started@as@a@reaction@to@the@highly unequ3@. health@system@imp. Ⅰ. mented@by@the@autho. 4.2.1@The@Universal@Health@System. ・. tarian@miliary@government@(1964-1985). Ⅱ. Sistema@Unico@de@Saude@(SUS). In@BraZl,@a@strong@socil@movement@in@the@hea and@bureaucrats. Ⅰ. h@field@began@in@1970.@among@professors,@par. In@the@Cv@@ soCety,@there@gradua. ，. Ⅰ. Ⅰ. amentarians,. y@emerged@a@saniary@movement@3med@at@the@radi. 3. transformation@of@the@na on ， s@health@sector@in@order@to@uniy@the@current@fragmented@system,@so@as@to@decentrali e Ⅰ. health@care@dC. ery@and@introduce@the@democratic@deciSon-making@process. Ⅰ. di cusSon@of@health@demands@and@hea. Ⅰ. ， The@1980's@were@a@pe. h@care@poli ies ， The@ 1988@BraZli. Ⅰ. Ⅰ. institutional@obstacles@of@the@health@care@reform@movement@in@Brazil and@ a@lack@of@a@so. Ⅰ. d@ mass@base@. in@the@ soCety. ・. Moreover,@. ・. od@of@intense. Constiuton@guarantees@univers8. n@. health@care@coverage,@which@gives@acitizens@equal@access@to@hea h@care. Ⅱ. Weyland@ (1995)@ examined@the. ・. These@obstacles@were@pervasi. e@clientalism. the@ state-centered@strategy@recorded@. accomplishment@although@it@did@have@some@positive@results@in@its@ear. Ⅰ. Ⅰ. mied. stages ，. Ar@cle@of@33@of@the@Basic@Law@of@Health@8,080@declared@that@the@financial@resources Saude@ (SUS)@ should@be@deposited@into@special@accounts@and@allocated@under@Ministry@of@Health@control@ (Brasil 2003). It@a o@dec red@that@finanC3@ resources@for@heah@care@come@from@sever3@ sources,@inCuding@the@soC3 security@budget@and@other@feder3@ budget@sources These@resources@are@adminitered@by@the@Mini try@of@Hea h Ⅰ. Ⅰ. Ⅰ. Ⅱ. ・. through@the@National@Health@Fund. The@Mini. ・. try@of@He8th@admi. i ters@matters@through@an@auditing@system@and. the@confirmation@of@health@care@programs@approved@as@the@resources@of@the@states@and@muniCpalities of@corrupti n@or@the@miappropr@. ti n@of@health@care@funds ， the@Mi. Ⅰ. ・. In@the@case. stry@of@Health@has@the@authority@to@appthe Ⅰ. ed@by@ w ，. necessary@punihments@as@determi. Ⅰ. Article@35@of@the@Basic@Law@of@Health@declared@that@the@establishment@of@the@amount@of@the@money@transfer to@states,@the@feder8@ditⅡ ct@and@muni. ip8ities@should@be@based@on@the@following@criteria@according@to@an@an3ysis. of@the@program ， s@techniqueS I，. II，. Region8@ demographic@profile Epidemiological｝rofiof》he〉eSdent｝opu tion Ⅰ. Ⅰ. III，. Quantitatve@and@qualiative@characteristics@of@the@hea h@care@system@in@these@areas. IV ，. Techni. V，. VI ，. Ⅰ. a,‘conomic,‖nd’inancil｝erformance（n‘a i r｝eriods Ⅱ. Distribution@to@the@health@sector@in@the@state@and@municipal@budget Provi i ns@of@the@five-year@p n@for@i vestment@@@ he3th Ⅰ. Moreover,@half@of@the@resources@to@. states@and@muni. ipal ies@are@di t buted@based@on@the@number@of Ⅰ. Ⅱ. residents. Law@8,142/90@regulated@community@participation@in@the@Universal@Health@System@and@the@intergovernmental financial@transfers@related@to@he3th@care ， The@SUS@established@the@following@organizations@within@each@sphere@of government;.
(6) 74. (216). 第 10巻第 2 号 (2005年 8 月 ). 横浜国際社会科学研究. Tab@. l stituti. 1. Health@Authority. n@. Structure｛f》heゞniversG Heath，areヾystem（n。razil. Functions. Decent. ア. Social@Control. allza Ⅱ on Process. Policy@Formation. Mechanism Counre@ors-5㈱. Govemmment md5. ㎝ Socie. ・. *"Central：und. Pede al ァ. *Na 廿 on 目 P0 Ⅱ ciesand. Minis 廿rryofHe 引山. Pr0gr. Na 廿 OOnalHe引山 Councll. 皿Ⅱ S. *Target@Programs 。 Sぬ teFu Ⅱ d State. *Health@care@centers Sね leHeal 山 C0unc. " unicipalFunds *Municipal@System al@Mu Ⅰ ci al@Secretary@of@Health@. Coordi. A.-M ㎝aeemenlof. Health@Care@System. ation. *Management@of De Ⅱnve 卍Ne ㎞ork Source:@Fleury. ㎡ s挺lC0@ ㎡ e丘 ence. Bip 沖. Ⅱ. Levels@of@Autonomy 市 e №。 杣. ㍉Ⅰ. Munici. 氏 nce. *Hospial@Financi3@resources. *@Re8on8@ System Coordination *Reference@Services. Sぬ tteSecre ぬ lryofHe 田田. Tnpa ㎡sanConfe. *Human@resources. Municip 田 Heal 伍 Counc Ⅱ. B-Management@of@the@Primary Health，are￣rogram. ， S ． (2001) ， p ， 20. (1)？ealth，onferences (2)@He3th@CounC. Ⅰ. A@Hea h@Council@consists@of@representatives@of@government,@service@providers,@hea h@speCalists,@and@users@of@the Ⅰ. Ⅰ. hea h@service， Ⅰ. Representa. Ⅰ. ves@of@users@must@comprise@50@percent@of@this@group. ・. Additiona. Ⅰ. y,@the@Hea. Ⅰ. h. Conferences@ and@the@Hea h@ Councis@have@func onal@organizations@and@rules@that@deTne@the@proper admlnls 比a Ⅱ onofeachCounc Ⅱ (Bras Ⅱ， 2003) Regarding@finanC3@ resources,@ Law@8142/90@declared@the@allocaton@of@the@financi3@ resources@from@the Ⅰ. Ⅰ. National@He3th@Fund@to@the@muni. i ali@ s,@states,@and@feder3@ di tricts@@@regular@and@automat@@ form ， In@order. for@the@munii alities,@states,@and@feder8@ districts@to@recCve@these@finanC3@ resources,@they@must@have@the@He3th Fund ， Health@Councils ， Health@Pan P. Ⅰ. ， Admi. strat* e@Report ， and@Commissi. n@based@on@occupaton,@posiion,@and@s3a. Ⅱ. es@(BraSl,@2003) A@@ muni ・. must@audit@the@resources@for@the@he3th@sector@budget. n@for@the@elaboration@of@the@Health ipali es,@states,@and@the@feder3@di tricts Ⅰ. ・. One@of@the@purposes@of@the@Basic@operational@Regulations@(NoB)@ 1991@was@to@treat@equal both@public@and (Brasil private@providers@based@on@a@financial@model@for@payment@to@both@private@and@public@service@providers@ Ⅰ. 2003) ， The@NoB@. 1991@was@administered@at@the@federal@level. ， through@the@National@Institute@of@Social@Security. (INAMPS) ， and@established@the@conventional@instrument@for@transferring@financial@resources@from@INAMPS@to@th states,@feder3@ districts@and@muni ipalii s ． Moreover,@it@enacted@the@muniCp3iza muniCp3ities@should@meet@8l@of@the@baSc@requiements. MuniCp3@ CounCl@of@a@He3th@and@MuniCp3@. Heath@Fund. Ⅰ. on@of@the@SUS@and@stated@that. The@first@requiement@@@. ・. ・. The@MuniCp3@. Health@serv@ e@planning@and@budgeLng@are@det@led@in@each@state@or@muni. NOB@ 1991@ a o@establi hed@an@agreement@between@the@INAMPS@. He8th@P. that@muni Ⅰ. ipa ties@create@a Ⅰ. n@approves@each@CounCl. ipal@health@plan@ (BraSl,@2003). ・. ・. The. (National@Institute@for@Medic3@ AsSstance@i. Ⅰ. SoC8@ Insurance)@ and@the@states@on@stimuting@the@resource@transfer@from@INAMPS@to@the@State@Secretary@of Ⅰ. He3th@and@the@Muni. i 3@ Secretary@of@Health. ・. 4.2.2@ Municipalization@of@Health@Care@Service@Delivery ation@and@the@Path@to@the The@9t@@National@Hea h@Conference@set@as@its@centr3@ theme@"MuniCp3i Muni i 3i a on"@ and@establi hed@the@Bi arti an@and@Tripartian@Commi Sons@as@important@venues@for@the Ⅰ. Ⅰ. negotiation,@contracting,@art@ ulation,@and@integraton@in@the@hea h@care@adminitration ， Addii Ⅰ. n3ly,@the@Nation3.
(7) The@Welfare@State@and@Health@Policy@ (Kazumi@Noguchi). (217)@ 75. Operation3@ Regulations@1993@(NoB@1993)@gave@muni ip3ities@the@authority@to@administer@the@health@care@system, which@was@an@unprecedented@step@on@the@path@to@a@decentr3ized@hea. The@flow@of@resources@was@based@on@the@. Ⅰ. h@care@policy@(BraSl,@2003). stage@of@management@autonomy@attained@by@the@. state@and. municipality@involved@in@the@NoB@1993@and@1996@respectively The@NoB@1993@esta6ished@three@4fferent@stages@of@management. ， wHch@were@steps@along@the@defi. ℡. te@path. ， 2002) ， toward@the@total@municipalization@of@the@health@care@services@(De@Souza. The@three@stages@were@the@following:@(1)@the@Incipient@Management@Stage@(2)@the@Partial@Management@and@(3)@th Semi-complete@Management@Stage. ・. Under@the@InCpint@Management@Stage,@the@muni ipaliy@formed@a@MuniCpal. Health@ Council@and@a@Municipal@Health@Fund@that@separated@health@resources@from@other@public@resources. Federal@resources,@transferred@through@the@state,@were@deposited@in@part@in@this@fund,@with@the@amount@depend on@the@ contracts,@ pub. Ⅰ. c@ or@p. Ⅱ. vate,@ already@signed@by@the@. municipa. Ⅰ. ty. ・. Furthermore,@. the@ muniCpaliy. partiCpated@in@setting@the@limits@for@inpatent@and@ambulatory@care@payments At@the@second@stage@of@management. ， the@Partial@Management@Stage. ， the@municipality@participated@in@the. financing@and@was@abto@recei e@the@difference@between@the@limis@on@inpatient@and@outpaLent@services@and@what Ⅰ. had@actu8ly@been@spent muni. ， As@for@the@thid@type@of@management,@the@Semi-complete@Management@Stage,@the. ipalty@took@complete@responsibility@for@providing@pub. Ⅰ. indi i u3@ health@servi es@through@publ@@ and@private@proⅤ ders. c@and@preven. Ⅰ. Such［uni ipa. ve@health@actvii Ⅰ. s,@ as@we@@ as. ties〉ece* ed》he’ull‖mount｛f. resources@up@to@the@speCfied@lim@@ (De@Souza,@2002) Under@the@NoB@1996.@only@two@management@Stuations@rem3ne4@. Complete@Management@of@BaSc@Care@and. Complete@Management@of@the@Munci. al@Health@System ，. the@requiements@of@the@former@InCpi. nt@Management@Stage. federal@resources@for@the@full@health@system@or@for@on. Under@either@of@them. ， the@mu. Ⅰ. cipaliies@had@to@fu @l Ⅰ. ， The@main@diference@was@in@the@abiliy@to@rece*. e. basic@care According@to@2001@ statistics， 4,952@of@5,560. Ⅰ. ・. municipalities@qualified@as@the@Complete@Management@of@Basic@Care@and@the@remaining@of@564@qualified@as@the Complete@Management@of@the@Muni. ip8@ Health@System@(De@Souza,@2002). ， 1). In@order@to@be@qu8ified@as@the@Complete@Management@of@BaSc@Care,@the@muni ip3iies@had@to@meet@cert3n tons@and@to@partiipate@in@the criteria,@which@inCuded@a@commiment@to@provide@the@basic@package@to@their@popu Ⅰ. implementation@of@information@systems@and@a@BaSc@Hea ev3uation@purposes. ， In@those@mun. Ⅰ. Ⅰ. h@Care@Agreement@used@for@both@monio. Ⅱ. ng@and. ip8ii s@that@did@not@qualify@as@eiher@management@category,@the@resources. were@controlled@by@the@state ， which@had@the@responsibility@to@bring@them@up@to@the@level@of@the@first@management situation@(Lobato@and@Burlandy ， 2000) Moreover,@both@NoB@ resources. 1993@and@1996@establihed@the@provi. ， The@first@method@was@the@automa. Ⅰ. ion@of@two@baSc@mechani. ms@for@transferⅡ ng. c@transfer@of@resources@from@the@feder8@ government@to@state@and. municipalities@for@primary@and@ambulatory@care,@based@on@popula@on@criteria ， Under@this@transfer@system,@the feder@@ government@presc inhabiant@of@the@muni. bed@the@transfer@of@a@fixed@amount@of@12@Brazilan@rea@@. Ⅱ. ipa ty Ⅰ. ・. Special@incentives@for@municipaltes@that@estab. programs,@such@as@famiy@doctors,@were@a. Ⅰ. o@presc. Ⅱ. (R$)2)@per@year@for@each Ⅰ. shed@baSc@primary@health. bed ， This@direct@transfer@from@the@feder3@. government@to. municipal@government@eliminated@the@role@of@the@state@to@3locate@the@resources@to@the@muni ip8ii s@(Lobato@and Burlandy,2000). ，. In@September,@2000.@Congress@approved@Constiu. Ⅰ. onal@Amendment@29@mandatng@an@increase@in@funding. levels@for@the@health@care@sector ， This@Constitution8@Amendment@requies@states@and@muni. ipalities@to@earmark. 12%@and@15%@respectvely@of@the own@revenue@for@health@and@the@federal@government@to@maint3n@the@fiscal@effort Ⅰ. attached@to@health@by@linking@growth@in@health@sector@financing@to@nominal@GDP@growth@(Wo. Ⅱ. d@Bank ， 2003).
(8) (218). 76. 第 10 巻第 2 号 (2005年 8 月 ). 横浜国際社会科学研究. The《econd［ethod｛f》ransfer『as》he‥iect》ransfer》o｝ubl@ and｝rivate”ea h｝ro Ⅴ ders,’or《ervices Ⅰ. re ⅠⅠ ng@to@hospi8@stays,@high comp Ⅰ. x@procedures,@and@ambu. Ⅰ. Ⅰ. tory@ser Ⅴ ces,@especi3 office@v@ is@ (Lobato Ⅰ. and。urlandy ， 2000) ，. 4.2.3@ Regionalization@of@Health@Care@Services The@federal@government@in@2001@issued@the@Normal@operational@Law@of@Health@Assistance@ (NOAS). The. ・. man@features@of@the@NoAS@are@the@promoton@of@greater@equiy@in@the@use@of@resources@and@access@by@the population@to@all@levels@of@health@care@(World@Bank ， 2003) ， In@order@to@prevent@the@continued@fragmentation@of@the. hea h《ystem｝lus》he‖ssoCated〕oss｛f‘conomi s｛f《c8e‖nd｛f》he《ize｛f》he〉isk｝ool,［uniCpalities『ere grouped@into@micro-regions This@built@on@NoB@96@by@expanding@the@use@of@per@capia@payments@to@cover@a@wider Ⅰ. ・. package｛f《ervices‖nd｜y…omPeting》he》ransfer｛f》he［anagement｛f’ederal’unds》o［icro re8ons ， ・. Some@new@features@of@NoAS@improved@equality@among@the@municipalities ， regulating@the@funds@distributed government》o》he［uniip8ii. from》he’eder8. s. ・. The’irst’eature . as@an@instrument@for@greater@equity@in@the@ditribuLon@of@feder3@ states》o‥ivide》he@. territory（nto［ul -muni. ip8. Ⅰ. 8locaton@of@feder3@ recurrent@funds@and@a. Ⅰ. resources. Ⅰ. ， Moreover,@the@NoAS@2001@requires. hea h［icro-regions‖nd》o「se》h@. as‖｜aSs’or》he. Ⅰ. o@for@investment@p. Ⅰ. nning ， The@second@characteris. establi hed@a@transparent@system@for@resource@3locaLon@across@mi. imp ment@speCfic@methodo. that》he¨oAS・. Ⅰ. c@of@NoAS@2001. ro-regions Th@@ system@requies@states@to ・. gi s,@plus@devCop@expli @@criteria@for@both@investment@as@weas@budget@p nning. Ⅰ. Ⅰ. Ⅰ. Budget@p nning@(uSng@Intergovernment3@Budget@Programming@Agreements)@estimates@the@financil@needs@of Ⅰ. each［uni ip8iy｜ased｛n》heヾze‖nd》he‘pidemiologi status｛f》he｝opula on‖nd‥ivides・ 3. transfers@to@muni i 3i@ manage》he@. s@ (grouped@@@. Ⅰ. micro-regi n)@based@on@the@@ needs ， Mi ro-regi ns@are@then@ent@ d@to Ⅰ. own》ransfers‖nd‖ssign》hem》o｝ay’or《peCfic《ervices（n》he@ territory｛r「se》hem》o｝ay’or. serVces@proVded@to@the@@. popu. Ⅰ. Ⅰ. on@e. Ⅰ. ewhere@(Wo. Ⅱ. d@Bank,@2003). Although》he（nfluence｛f》he¨oAS・. mi ro-regi ns@are@undefined ， Three@mode. ， the“overnance‖nd［anagement’or》he. of@the@management@are@presen y@being@tested@in@diferent@parts@of Ⅰ. Ⅰ. Brazi ， In，eara,31》he［icro-regions‖re［ainly［anaged｜y》he〉egi n3 outposts｛f》he《tate”ea h《ecretariat with@varying@degrees@of@partiipation@by@muniip3iies In@some@areas@of@Brazil,@micro-regins@are@formed@by@a consortia@of@muniip3ities@that@create@an@ad@hoc@agency@for@managing@hea h@care@wihout@part@ipaton@of@the Ⅰ. ・. Ⅰ. state ， In@other@states@of@BraZl,@the@muni sma. ip8i es@are@allowed@to@manage@part@of@the@budget@of@neighbo. er@muni ipa ties@(sate ies)@ wih@varying@participaton@of@the@sate. Ⅰ. Ⅰ. Ⅰ. Ⅱ. Ⅰ. Ⅰ. ng. ies@and@of@the@state@in@the@daiy. management｛f〉esources｛r（n…ontrol Diferent［anagement《tYes‖re［ore kCy》o｜e（nfluenced｜y》he Ⅰ. ・. politic3@ affili on@of@the@parti ipaLng@mayors@and@state@governments@than@by@techni There . a. Ⅰ. oヽegion3i aton．iector￣ (PDR) n. Ⅰ. consideraLons@of@deSgn. 3@. Ⅰ. Among》hese〉egions,『hich”ea h《ervi es『@l｜e Ⅰ. ・. transferred@depends@on@vaFous@servi es@needed PDR@@@ coordinated@by@the@State@Hea h@Secretary Each@state@i Ⅰ. ・. ・. subdivided｜y［odules,［iro-regions,‖nd［acro-regions Methods‖nd…oncepts‖dopted‥ifer‖mong《tates, ・. reflecLng@speci3@characteris cs@of@each@state ， More@importanLy,@the@macro-region@@@ Ⅰ. high》echnology［edi serVces 3. ・. the@suppli r@of@terti ry@or. In》he〉egi n,》he”ea h［anagers‖re’u y〉esponSb for（den fying》he Ⅰ. Ⅰ. Ⅰ. Ⅰ. resources@and@cooperation@needed@to@promote@the@health@serv@ e@qu3iy@(Miniterio@da@Saude,@2004) Theゞniversal？ealthヾystem‖ndヽegionalization. 4.2.3.1. There@are@sever3@agendas@for@the@regin3i ation@of@the@uni ers@@ health@care@system ， It@is@essenLal@to@define the〉o. Ⅰ. of‘ach“overnment（n》he〉egi n3izati n‖nd…o-management『ih》he「nivers3 he3th《ystem‖nd》o. establi h@a@more@s0@@ financi l@mechani m@@@ concert@wih@the@uni In》he「ni ers3. ers8@. he8th@system. hea h《ystem,》he”ea h〉egions‖ssume‖」it3 importance（n〉elaLon》o》he｝erformance Ⅰ. Ⅰ.
(9) (219). The@Welfare@State@and@Health@P0y@ (Kazumi@NogucL) Ⅰ. of@health@poliy The@hea. Ⅰ. ・. h@regi ns@are@di ided@by@territories@composed@of@one@or@more@cii. the@cultural， economical ， and@social@environment characte. Ⅱ. 77. s@and@are@based@on. ， A@health@region@should@be@organized@based@on@the@identical. stcs@of@territo 3@ spaces@and@formed@wih@10-15@muni Ⅱ. ip8ities@(Miniterio@da@Saude,@2004). The@region@should@have@strategi s,@programs@and@proects@whi h@3l@reflect@the@partiular@needs@of@the@regin as follows. @@Creation@of@region3@ management @@Insta aLon@of@regul Ⅰ. Ⅰ. on@of@centr3@ offices. @@Accompli hment@of@region8@ agreements @@Qualifyi g@the@managers @@Qu8iying@of@3l@muni. ipa ties@in@the@regi n Ⅰ. @@Guarantee@for@risk@situations@to@cit@ ens. @@Guarantee@of@basic@attenLon@to@citizens @@Regionalized@hospi8@ attenLon @@Guarantee@of@urgency@and@emergency@serv@. es. @@Integration@of@humanizaLon@pr0ects @@Permanent@education@structure @@Re8onalizati @@Region3i. n@of@oral@health， mental@health ， and@labor@health. aton@of@health@monito. Ⅱ. ng. @@Popular@pharmacy@implantation 4.2.3.2@ The@Role@of@the@Government@in@the@Regionalization It@@@very@important@to@identiy@the@task@shared@by@the@three@spheres@of@the@government@in@regi. n3i. because@of@the@complex@system@of@the@universal@health@system Municipalities@should@be@responsible@for@the@following@tasks. @@Take@part@in@regional@organi aLon,@making@services@available@for@all@citizens @@Parti ipate@in@the@regi nali ation@through@managers. @@Hire@skilled@workers @@Cooperate@in@prioritized@pr0ects@for@regi nal@health@devCopment @@Motvate@soC3@parti ipaⅠ on@in@the@region @@Ca for@technic3@ support@from@other@government@spheres Ⅰ. The@state@should@be@responSb. @@Coordina. Ⅰ. fo Ⅱ. Ⅰ. ng@and@provide@techni. @@. support@in@the@process@of@the@healh@regions. @@Iden fyi g@the@needs@of@itegration@with@@ the@he3th@regions Ⅰ. @@Parti ipating@in@regi nal@mee. Ⅰ. ngs. @@Inst3ling@services@@@ the@regi ns @@ProVding@technical@and@logis. Ⅰ. c3@. support@to@other@spheres. @@PlaCng@the@health@workers@who@make@perSstent@information@av3. Ⅰ. b. Ⅰ. to@hea h@regi ns Ⅰ. @@Moti ating@soci6@ participation@in@the@regi ns @@Organi i. g，. analyZng@and@making@available@all@information@gi. en@by@the@health@regins. @@Cooperating@financially@to@reduce@any@inequalities@in@the@regions @@Establishing@the@references@in@the@case@of@proVding@the@high@complexity@medical@services. a Ⅰ on.
(10) (220). 78. 第 10巻第 2 号 (2005年 8. 横浜国際社会科学研究. The@feder8@ government@shou. 月). be@responsib@@ for. Ⅰ. @@Pro Ⅴ ding@the@support@to@the@he8th@regins. @@Cooperati g@finanC3 w@h@other@spheres@of@government @@Gi ing@techni 8@ and@finanC3@support@to@vulnerabregi ns Ⅰ. Ⅰ. @@Integrat@ n@of@the@priority@of@the@feder3@government@program@@@ regi n@@ deve pment 8@ support@to@the@state @@ProVding@the@techni Ⅰ. @@Di cusSng@and@propose@a. Ⅰ. erna. Ⅰ. ve@too. @@Proposing@and@identifying@3l@posSb @@CoordinaLng@the@integra. Ⅰ. Ⅰ. for@region3@agreement. strategi s@for@SUS@in@the@regi ns. on@of@interstate@regions. Ⅰ. In@co-management@with@SUS ， the@autonomy@of@the@each@government@sphere@should@be@guaranteed ， especial the Ⅰ. muni. ip@@ government@(Ministerio@da@Saude,@2004). 4.2.4 NOAS 2002 The@main@changes@in@NoAS/SUS@01/01 ， introduced@by@NoAS/SUS@01/02@were: can@be@as@enti d@as@the@Muni ipa (1)@The@muniCp3ity@whi h@serves@as@the@headquarters@of@an@asSstance@un@@ System@P nary@Adminitra on@in@the@case@of@a@sing muni ip3@ command@or@as@the@Extended@BaSc@Atten Ⅰ on Ⅰ. Ⅰ. Ⅰ. Ⅰ. Plenary@Administration@(GPABA)@in@the@case@of@single@state@command. (2)@NOAS fol. Ⅰ. SUS@01/2002@established@the@fact@that@the@financi l@assi tance@lim@@ for@each@state， sh8l@present@the. wing. Ⅰ. a@finanC3@ asSstance@ mit@wi be@imposed@on@every@state,@regardl. a．. Ⅰ. ss@of@is@adminitra@on@condi. Ⅰ. Ⅰ. on. b ． conditions@of@adminitration@of@each@muni ip3ity,@or@vel@of@government,@are@responSbfor@medium@and@high Ⅰ. Ⅰ. complexity@command c．. share@of@financi3@ resources@for@the@attendance@of@reSdents@under@municipal@admini. traton. resources@for@the@attendance@of@inter-municip3@ references d ， share@of@financi8@ e. share@of@financi8@ resources@for@the@attendance@of@reSdents@under@state@admini. ・. tration，. f． other@finanC8@resources@under@state@administration,@3located@in@muni ip3ities@or@in@states g. ・. global@financial@limits@of@each@state ， the@sum@of@items@c ， d ， e@and@f，. (3)@NOAS Ⅰ SUS@01/2002@established@that@the@states@are@responsib for@the@admi istratin@of@publ@@ unis@of boratories@and@for@information@regarding@quaity@control,@saniary,@and@epidemiologi 8@ vigiance@and@public Ⅰ. Ⅰ. hea h@ boratories Ⅰ. Ⅰ. ・. 4.2.5@Expansion@of@Services@Provided@at@the@Municipal@Level The@NoAS@2001@c3ls@for@an@expansion@in@baSc@he3th@care@and@requies@muniCp8ities@to@pro Ⅴde@a@wi er array@of@serVces@(now@cad@PAB-ampliado@or@PAB-A)4'@to@the@@ popu tions SerVces@must@now@include@care@for the@control@of@tubercu Ss,@Hansen's@diease,@hypertenSon,@di betes,@childcare,@as@we as@matern3.@and@dent8 Ⅰ. Ⅰ. ・. Ⅰ. care ．. Ⅰ. In@addii n,@a@new@feature@of@the@NoAS@2001@reinforces@equiy@by@expanding@the@use@of@capiation@systems. and@increases@the@share@of@funds@that@are@dist buted@automaLca Ⅱ. increaSng@the@v3ue@of@capita. Ⅰ. ons@associated@w@h@PAB-A. Ⅰ. y@on@a@per-capia@baSs@to@muni ip3iies,@by. ，. The@referral@system@among@the@mi ro-regi ns,@whi h@@@ part@of@the@NoAS@2001.@@@a o@one@of@the@new features， The@NoAS@2001@establihes@more@transparent@systems@to@manage@care@at@the@loc3@ vel@based@on@the Ⅰ. Ⅰ. use@of@networks@and@requires@mi ro-regions@to@imp ment@better@management@too Ⅰ. medium@complexiy@health@care@to@the@@ preven. Ⅰ. popula. ve@care@and@to@ration3ie@the@use@of@compl. profesSona. Ⅰ. to@prioritize@access@to@compl x@care. Ⅰ. ons ，. These@management@too. to@improve@the@regulation@of. Ⅰ. Ⅰ. wil@be@used@to@emphaSze. x@care@by@strengthening@the@use@of@referra. Ⅰ. from@baSc@care.
(11) ℡ eWeU Furthermore,@the@NoAS@2001@ performance@of@muni. enSUnngthec0mP. 肛 eS. ㌶. ぬteand Heal 由 Pol;cy (K umiN0%ch. makes@the@ state@responSble@for@both@ monioring@and@evalua. ipalii s@in@the@implementation@of@key@health@programs Ⅱ. (221). け. anCeofmunlclpa. Ⅱ廿. eSwlththebaSlcc. ng@the. States@become@responsib. ・. 「. for. Ⅰ. ㎞ ce ㎏ reements.. ぬ getssetbyBaSlcAsslS. 肛e. also@become@responSble@for@ensuring@that@sm3l@muni. Ⅰ. 79. S ぬteS. ipalities@obt3n@effec Ⅰ ve@access@to@referrals@for@servi es. provided@in@large@municipalities@(Brasil ， 2003). 4.2.6@ Community@Participation@in@the@Decision-Making@Process@of@the@SUS The@federal@legislation ， Article@of@the@Constitution@and@the@Law@of@8080/90@established@the@general@principles ，. whi h@inCude@communiy@part@. ipation@in@the@adminitration@of@the@Un*ersal@Health@Care@System@by@forming@the. Health@Conferences@and@the@Health@Councils@that@are@regulated@by@article@1@of@Law@8142 The@ Hea admini tra. Ⅰ. h@ Conferences@. Ⅰ. on. are@. the@ consu. Ⅰ. ation@ bodies@ whi h@ exerci e@ soci8@ control@ over@ hea. ， Moreover,@they@have@the@function@of@assessing@the@hea. hea h@care@po Ⅰ. cy@at@each@level@of@government,@whi. Ⅰ. Ⅰ. h@care@Stua. Ⅰ. h@ care. on@and@of@propoSng@the. Ⅰ. h@gives@cii ens@the@right@to@partCpate@in@health@care. administration ， Proper@Health@Conferences@must@be@establi. hed@in@four@years， while@the@m3n@ro. of@the@Health. Ⅰ. Conferences@is@to@di cuss@various@predetermined@issues@in@order@to@adopt@both@related@hea h@sector@agenda@and Ⅰ. practic3@ guidCines@for@the@upcoming@period@(BraSl,@2003). ，. The@Health@Councils@have@a@diferent@funcLon@from@that@of@the@Health@Conferences. ， They@are@more@focused. on@he8th@care@deciSons@and@p0icy@making,@by@making@efforts@to@participate@@@ discusSon@concerning@health@care p0i y@i cludi g@the@independent@acti. iy@of@the@government. Although@the@Health@CounC. ・. Ⅰ. are@part@of@the. government@structure,@and@the@p ce@where@the@interests@of@diferent@segments@of@the@soc ty@converge,@they@have Ⅰ. Ⅰ. made@@@ posSble@to@negotate@the@proposa d ㎡erentphoh. は es. Ⅰ. and@to@deCde@the@direc. on@of@the@flow@of@resources@based@upon. (Brasil,2003). The@Law@of@8142/90@stipulated@that@the@Health@CounC. percent@of@the@@ membership@composed@of@government3@ Ⅰ. Ⅰ. Ⅰ. are@a@permanent@and@deliberative@organ,@w@h@50. representatives@and@of@representatives@of@the@soci ty@at. rge,@inCudi g@health@care@users,@pro Ⅴ ders,@and@speC8ists ， Th@@ structure@enab. supervise@health@care@deci i n@making,@budgeting,@and@poli. Ⅰ. s@Ct@ ens@to@partiCpate@@@ and. y@execution@(BraSl,@2003). SoC3@ Control@in@the@case@of@Ceara3@p ys@an@important@ro in@the@d cusSon@and@poliy@making@of@healh Ⅰ. c 肛 epoIicy.. Ano 伍 ceroftheSecre. need@of@the@hea. Ⅰ. ぬryrofHealthofCear. 養. men. 廿. Ⅰ. onedthatsocl. h@care@users@which@represents@50@percent@of@the@Health@CounCl. Ⅰ. 引 con 比olexlststodetermnlne ， Among@representa. Ⅰ. ぬe. ves@of@the. hea h@care@users,@the@communiy@health@agents@(explained@ ter@th@@paper)@are@important@advocates@for@ci@ en's Ⅰ. Ⅰ. interests， The@members@of@the@State@Health@Council@hold@a@monthly@meeting@to@dscuss@health@care@policy. ， At@a. meeting@in@July@2003.@representatives@of@the@government@included@the@Secretary@of@Hea h@of@Ceara,@the@Minitry Ⅰ. of@Health,@the@Minitry@of@Educa Ⅰ on@and@Culture,@the@Council@of@State@and@MuniCp8iy@of@Hea h,@the@LegiSa Ⅰ. Assembly,@the@AssoCa. on@for@Mayors@of@Ceara,@the@Secretary@of@BaSc@Educa. Ⅰ. In 止ast丁Ⅱc 抽丘e. Assewlceprovlde Ⅱ. 丘. s,theFede. in@Ceara@attended@the@State@He3th@CounCl inCuded@medi. 3@. Ⅱ. ・. atlonofPh. Ⅱ. anth oplesofCe 丘. Ⅰ. ve. on,@and@ the@Secretary@of. Ⅰ. 肛后 andtheAss0clatlonf0rHospl. ぬls. Medical@profesSonals@who@partiCpated@in@the@Health@CounCl. assoCati n@representatives,@nurses@and@dentists. Most@of@the@muni. i 8ities@have@health@care@counC. Ⅰ・. 9@ In@most@of@muniCpali. Ⅰ. s@there@are@ten@muni. i al. counCls@whi h@cover@not@only@the@i sues@of@education,@health,@and@ bor@but@also@intersectional@iems ． Health@care Ⅰ. issues@overlap@a of@the@muni ip3@counCls ， A@new@program@was@launched@to@combat@domestic@ Ⅴo nce@against Ⅰ. adolescents@and@children nurses,@ educa. Ⅰ. Ⅰ. ・. At@a@seminar@for@th@@ program,@there@was@interdisciplinary@cooperation@among@doctors,. soci l@workers,@health@agents,@educators,@ and@directors@of@the@counc@@and@members@of@the@council@of on.
(12) (222). 80. Some@scho. 第 10巻第 2 号 (2005年 8 月 ). 横浜国際社会科学研究. rs@have@exami ed@the@effectieness@of@the@he8th@care@counCls ， Souza@(2002)@ argues@that@the. Ⅰ. soC8@ poli y@counC. inCuding@hea. Ⅰ. counci@@ are@a@form3@reproduc. Ⅰ. h@poli y@counC. Ⅰ. Ⅰ. are@just@a@form3iy@of@the@system. on@of@what@the@rules@say,@undermining@fundament8@. Moreover,@there@@@an@accusaton@that@sub-na. on3@ e. Ⅰ. ， Many@communiy. assump. Ⅰ. ons@of@partiipation. tes@exerCse@control@over@these@counCls. Ⅰ. Moreover,@CoCho@argues@that@state@and@soC3@ actors@in@the@saniary@movement@(the@soCal@movement@for health@reform@in@Brazil@started@from@the@1970 ， s)@failed@to@establish@the@health@council@as@the@dynamic@political instituLon CoCho@uses@the@muni ip3@hea h@councils@in@Sao@Paulo@as@an@example@and@presents@sever8@ problems Ⅰ. ・. in@these@health@counC. ， Firstly,@the@representaLon@and@criteria@for@organiZng@politic8@ representa. Ⅰ. Ⅰ. on@@@ the@one. matter@for@the@health@counci， In@the@case@of@secting@the@representatives@of@CVl@society@to@the@health@counci Ⅰ. Ⅰ. there@@@ no@raLon3e@involved@in@the@se. Ⅰ. ction@process@and@for@determining@the@exact@number@of@seats@availab. Ⅰ. ,. Ⅰ. for. this@group. The@ second@ i sue@is@the@ organi. a. of@procedures@for@di. on@. Ⅰ. parti ipatory@arena ， In@the@muniCpal@hea h@counci ,@m8or@ro Ⅰ. Ⅰ. counc@@ or@the@chairperson@of@the@sesSon,@whi. as@hea h@counC Ⅰ. Ⅰ. cusSon@. s@were@p. Ⅰ. on@as@poliic3@instituⅠ ons. government@officia. and@med. Ⅰ. Ⅰ. Ⅰ. proVders@(CoCho,@2004). @@. ・. ip8@ hea h@counC Ⅰ. Schonleiner@ (2004)@ argues@that@only@pos ive@interac on@among@polii Ⅰ. Ⅰ. instiution@make@dCiberation@work@through@h@@ es@in@po. Ⅰ. The@body. ， Some@representatives@of@the@Cvil@soCety@are@in@fact@ ss@educated@than@the. There@@@ another@an3ysis@regarding@the@effectveness@of@the@muni. Ⅱ. ・. should@guarantee@sharing@various@opini ns@and@having@the@equ8@opportunity@of@speaking@on@3l. Ⅰ. i sues@among@the@counCl@members. va. a. yed@by@the@execuLve@secretary@of@the. Ⅰ. h@were@inadequate@as@a@func. and@ deci ion@ making@suied@to@. tic8@ commitment,@Cvi. Ⅰ. commitment,@ Cvi ness,@and. 8@. case@studi s@in@four@muni ip8ii s@in@Brazil， Each@municip3ity. ness,@and@institu. Ⅰ. ons@and@has@some@diferent@outcomes@of@the@health@counC. Ⅰ. 4.2.7.@ Community@Participation@in@the@Implementation@Process@of@Health@Policy. 7. 七久. Program｛f》he，ommunity？ealth、gents・. .1. The@pilot@program@of@Community@Health@Agents@(PACS)@was@launched@at@the@University@of@Brasilia@in@1974 and@1978@(Lavor@et@al ，， 2004) ， For@the@Pilot@Project ， the@University@of@Brasilia ， government@of@the@Federal@District ， the@KClogg@Founda. Ⅰ. on@and@the@Inter-American@FoundaLon@were@assemb. the@experiment@to@control@schistosomi Ss@within@the@communii. Ⅰ. d ， The@idea@was@to@take@advantage@of. s@in@Pernambuco@(at@the@end@of@the@1940's). through@publ@@ education@efforts Through@the@prac ce@and@performance@of@hea h@agents,@heah@profesSona Ⅰ. ・. discovered@that@the@s0uti. n@for@many@prob. Ⅰ. ms@wihin@that@popu. Ⅰ. Ⅰ. Ⅰ. Ⅰ. t@ n@was@not@@@ the@hosPt3@ but@rather@@@ the. realm@of@the@fami and@community Ⅰ. P or@to@the@na on3ia. on@of@the@Program@for@the@Communiy@Hea h@Agents,@in@the@early@1980's,@Dr Lavor mented@th@@ program@in@the@state@Ceara@for@the@first@time@and@suggested@th@@ idea@to@Tasso@Jerei sati@who Ⅱ. imp. Ⅰ. Ⅰ. Ⅰ. Ⅰ. ・. became@the@governor@of@Ceara@in@1986. In@1987 ， the@state@of@Ceara@experienced@a@severe@drought@and@hired@men@to@build@an@irrigation@system @@ hied@6,000@women@as@community@hea chidren,@ tuberculoSs@pa. Ⅰ. Ⅰ. h@agents@who@were@responsible@for@iden. ents,@ and@infants@in@need@ of@immuni. categorized@as@priary@health@care@services@ (Lavor@et@al， 2004) ・. Ⅰ. ， while. fying@pregnant@women,@young. ation,@ 8l@of@whom@regarded@attention@that@i ・. In@Ceara@there@were@3,433@community@health. agents@in@ 1990 ， 7,818@agents@in@1994@as@total ， and@ 11591@ in@2002@ (IPLANCE. ， 2003). ・. In@ 1991 ， the@PACS@was. launched@as@the@national@program@and@the@Program@of@Fami He3th@was@commenced@in@ 1994.@ In@the@city@of Ⅰ・ Since Maranguape,61@there@were@123@communiy@health@agents@who@assisted@16,602@famii s@and@74,186@peop Ⅰ. then,@they@have@been@p. Ⅰ. ying@an@important@ro. Ⅰ. as@a@b dge@between@Ctizens@and@doctors Ⅱ. The…ompensation’or》he‖gents p3d｜y》he《tate“overnment（n，eara,7'‖hough》he…ommuniy”ea h Ⅰ. Ⅰ.
(13) The@Welfare@State@and@He3th@Policy@ (Kazumi@Noguchi) agents@are@not@conSdered@publ@@. servants. (223). 81. Qualificati ns@for@the@communiy@health@agent@are@as@f0lowS@. ・. resident@of@the@ditrict@and@a@high@school@graduate ， Regarding@selec. Ⅰ. on,@the@municipal@government@car. a Ⅱ. ed@out. the@se ction@process ， Since@the@work@of@the@community@hea h@agents@has@become@more@speci li ed@after@twenty Ⅰ. Ⅰ. of@years@of@the@imp. menta. Ⅰ. Ⅰ. on@of@this@community@hea. Ⅰ. h@agents@program,@there@exists@an@argument@that@they. need@to@have@highly@specialized@training@from@both@social@workers@and@psychologists. The@city@of@Sobral@in@Ceara. ・. financed@and@implemented@a@pilot@program@one@year@ago@for@a@two@year@training@program@for@high@school@graduat community@health@agents. ・. As@for@future@prospect ， community@health@agents@should@be@multi-specialists@and residents@more@profoundly. should@be@able@to@communicate@wih@the@@. Communiy@hea. Ⅰ. h@agents@formed@an@assoCaton@whi. Th@@ associaLon@establi hed@a@contract@w@h@the@state@whi to@communiy@hea. ，. h@@@ one@of@the@strongest@interest@groups@in@Brazi h@@@ responSble@for@paying@the@necessary@compensation. h@agents@(Lavor@et@al ,@2004)， There@is@a@movement@for@giving@the@censes,@however,@there@has. Ⅰ. Ⅰ. ・. been@some@concern@regarding@th@@ point,@Snce@licenSng@could@take@the@@ interest@and@commiment@away@from@the districts@where@they@serve@as@the@agents@and@could@ ad@them@to@become@ Ⅰ. Ⅰ. ss@responsive@to@the@need@of@reSdents ，. The@he3th@agents@are@p3d@by@the@state@government@and@the@se cti n@of@the@commuHty@he3th@agents@@@ carried Ⅰ. out@by@the@muHci. al@government. ・. 4.2.7.2 The Fam Ⅱy Health Program The@Fami the@Commu. Health@Program@(PSF)@was@launched@@@. Ⅰ. Ⅰ. (PSF). ty@Health@Agent@Program. 1994 ， b ℡Ⅰ i g@on@the@strength@of@its@1991@predecessor ，. ， PSF@was@concei. curative@and@hospial-centered@health@care@ inter-section3@ integra on@and@baSc@hea Ⅰ. Ⅰ. ed@as@a@li chpin@@@ the@transformation@of@the@mai. system@toward@one@that@@@. oⅡ. ented@toward@prevention,@. ・. Ⅰ. Ⅰ. tions@in@a@proactive@manne. Ⅱ. eventu3ly@these@serVces@are@expected. to@serve@as@an@entry@point@to@highervC@ services， Under@the@PSF,@a@team@conSsts@of@community@hea Ⅰ. prac. Ⅰ. ce@or@family@hea. Ⅰ. h@physiCan,@a@nurse,@one@or@two@auxili. Ⅰ. an@popula. Ⅰ. Ⅰ. h@agents,@a. ry@nurses,@and@part-time@denti. team@@@ asSgned@the@responSbiliy@of@proVding@care@to@a@pre-defined@set@of@fam nearly@one-fourth@of@the@entire@BraZ. promotion,. h@care@(Lavor@et@8 ， ,@2004) The@program@seeks@to@devCop@high@qu3iy. primary@servi es@that@serve@vulnerab popu gener3@. Ⅰ. Ⅰ. ies. ・. Na. Ⅰ. ona. Ⅰ. ts， Each. y,@the@PSF@covers. It@@@one@of@the@largest@federally-funded@health@programs,. on ，. spending@US$380@million ， Under@current@government@plans ， in@the@near@future@the@PSF@will@provide@coverage@to 50@percent@of@the@BraZlian@popu. Ⅰ. Lon. 4.3@ Brazilian@ Health@Administration 4.3.1@ Role@of@Each@Level@of@the@Health@Ministry@of@the@SUS Hea. Ⅰ. h@ care@po. cy@must@comply@with@the@fo. Ⅰ. poli ies@and@planning;@financC@. coordina. Ⅰ. owing@four@m3or@admini. Ⅰ. oH@ regu. Ⅰ. Ⅰ. oⅠ. tra. Ⅰ. ve@func. onS@. Ⅰ. formulation@of. control@and@ev3uation@of@the@SUS;@and@direct@assi. tance. for@health@services@(De@Souza,@2002) 、 Each@m3or@functon@includes@a@series@of@sub-functions@and@administrative authority@in@the@hea. Ⅰ. h@care@sector ， For@instance,@one@of@the@four@functions,@the@formu. tion@of@po Ces@and. Ⅰ. Ⅰ. planning， includes@the@diagnosis@of@the@necessity@of@public@health@as@well@as@the@identification@of@m3or@priorities and@programs@of@hea 4.3.1.l. Ⅰ. h@care@acLviies. The ⅣIinistで y 0fHealth. in B Ⅰ azil. In@gener8.@the@role@of@the@Minitry@of@Hea h@ (MS)@ @@ to@estab sh@the@strategis@of@the@heah@care@of@the Ⅰ. naton@on@the@who decentr3i. Ⅰ. and@focus@on@planning,@contro. Ⅰ. Ⅰ. ation@(De@Souza,@2002) ， Moreover,@the@Mini. for@three@national@systems;@complex@medical@treatments. Other〉o Ⅰ. s. of》he. ing,@ev8ua. Ⅰ. Ⅰ. ng@and@audiing@to@check@the@process@of@the. try@of@Hea h@has@focused@on@definition@and@coordina. Ⅰ. Ⅰ. on. ， public@health@laboratories ， blood@dia sis Ⅰ. Ministry｛f？ea h‖re》o〉egulate》he｝rivatesectors, and》o，a fy》he〉egula ons Ⅰ. Ⅱ. Ⅰ.
(14) 第 10 巻第 2 号 (2005年 8 月 ). 横浜国際社会科学研究. (224). 82. pertai ing@to@both@the@SUS@and@private@health@services In@ad4tion ， the@Ministry@of@Health@estaDishes@the@criteria ・. and@remuneraton@for@serVces@w@h@the@approv3@ of@the@Nation8@Council@of@Heah ． Within@the@SUS,@the@Mini try Ⅰ. of@Health@has@the@task@of@identifying@the@health@care@services@at@state@and@municipal@levels@and@of@establishing@the techni 3@ mode. for@hea h@care@assistance. Ⅰ. Ⅰ. Many@responsi. ilities@are@imposed@on@the@Miistry@of@Health@@@ the@area@of@admi istration@of@the@SUS Frst ， ・. the@MS@e borates@the@natinal@plan@of@the@SUS@@@regard@to@the@techni 8@ cooperat Ⅰ. and@the@feder3@ di trict Regarding@region3i. a. ・. p0iy@making@(De@Souza,@2002). Ⅰ. on@of@asSstance,@the@MS@@@. pro Ⅴ ders. n@with@states,@muni ipalities. responSb. for@fo owing@areas@of Ⅰ. Ⅰ. ，. @@Defini g@regulat@ ns,@and@the@techni 8@ instruments@for@the@imp. Operaton8. such‖s¨orm3. Ⅰ. Law. Ⅰ. mentat@ n@for@these@regu t@ nS@ for@the@SUS Ⅰ. (NOAS) and〉egu ng〉e ti ns｜etween》heヾUS‖nd｝Fvate《ervi e Ⅰ. Ⅰ. Ⅰ. ・. @@Pro Ⅴ di g@finanCal@cooperation@for@states@to@claLfy@the@plan@and@to@imp ment@the@p n@w@hing@the@state@he3th Ⅰ. Ⅰ. care@system. @@Provide@both@technic8@ and@financi3@cooperation@to@states,@the@feder3@ di trict@and@municipaliies,@in@order@to achieve@the@perfect@institutonal@8ms ， @@Admi. istering@a@reference@system@among@states. @Control@and@ev8uate@hea The@chi. h@care@servies,@espeCally@the@competence@of@states@and@muniCpai@. Ⅰ. f@of@the@decentr8iza. Ⅰ. on@sec. Ⅰ. on@of@the@Ministry@of@Health@men. Ⅰ. s. ・. oned@at@an@interview@that@it@was. important@to@regute@the@re Lonships@between@the@SUS@and@private@health@care@providers,@Snce@many@patients Ⅰ. come@to@the@pub. Ⅰ. Ⅰ. c@hospit8@ for@advanced@treatment@under@the@SUS@. treatment@under@the@SUS@has@become@a@prob treatment@at@publ@@hospia. Ⅰ. admi. Ⅰ. ， Moreover,@the@i. sue@of@payment@for@medi. 3. m@Snce@many@patients@insured@under@private@he8th@p ns@recei. e. Ⅰ. i tered@under@the@SUS@and@the@cost@of@the@@. treatment@@@ p8d@by@the@SUS. ・. Some@argue@that@the@private@i surance@compani s@have@a@duty@to@pay@the@costs@for@the@insured@even@though@the medi 8@ treatments@are@performed@at@a@publ@@ hospial ， Moreover,@the@Mini. try@of@Health@defnes@and@regu. Ⅰ. tes@the@techni. al@coopera. Ⅰ. on@between@na. on3. Ⅰ. instiuLons@of@Nation8@ Blood,@Components@and@Devices@and@the@Publ@@ Health@Care@Laboratories,@and@contro and@coordinates@the@integraLon@of@highly@compli ated@hea h@care@asSstance@ (De@Souza,@2002) Furthermore, the@ro of@the@MS@is@extended@to@the@carrying@out@the@direct@control@over@the@reduc Ⅰ on@of@dispa Ⅱties@across@the Ⅰ. Ⅰ. ・. Ⅰ. country. ，. In@sum,@the@federal@government@aims@at@regulating@and@controlling@the@national@health@care@system@on@the whole. 4.3.1.2 The State Secretary ofHealth to@plan,@program@and@organize@the@regi nal@organ@ ations@and The@role@of@the@State@Secretary@of@Health@@@ CasSfication@of@the@SUS@at@the@state@levC@ (De@Souza,@2002) The@State@Secretary@@@responSb for@articu ting Ⅰ. ・. and@conso admini. Ⅰ. da ng@the@region3i. aton,@and@integration@of@the@program@in@the@states@and@for@imp. Ⅰ. te ng@regulations@wihin@the@state Ⅱ. ・. Moreover,@@@. has@responSbiiy@for@admini. Ⅰ. Ⅰ. men. ng@and. Ⅰ. te ng@the@reference Ⅱ. system@among@municipalities@and@coordinating@the@building@of@collaboration@among@the@public@medical organi. a. Ⅰ. ons@for@high. recelveassls ぬnce wihin@the@state. Ⅰ五二. Ⅰ. comp. omtheM. Ⅰ. Ⅰ. x@medi. 8@. treatments. ・. In@re tion@wih@the@Mini Ⅰ. rnls 町 ofHealthforthehlghlycomplexmedlcalc. try@of@Health,@the@state@will. 肛ethatcannotbe. ぬkencareof. ，. There@are@other@general@functions@for@the@coordination@and@regu tion@of@the@state@health@care@system States Ⅰ. ・. need@to@cooperate@with@muni ip8i@ s@over@the@techni3@ and@finanC3@matters,@as@well@as@establih@regulations,@i.
(15) The@Welfare@State@and@Health@Policy@ (Kazumi@Noguchi) Table@2@ Policy@Formulation e. "[den Ⅴ [hep 0blems 皿 d decision0 Ⅱ hep0 cyasnau0n Ⅲ pn0 iⅡ eS れテ. Tab@@ Municipal. State. Ⅰ de 「 al ト. ァ. *Identify@the@problems@and deci ion@as@national@priorities. Municipal. d. "'"p 。""'" 。 。。 穫 。 ra@r 。 so'urces. 'ReditLbution@of@financia. *Pr0m0te 山 ere 陣 0n 由 izaⅡ 0n. *Guarantee｛f｝roper‖loca@on of@resource. sources. Planning@of@necessary@actions and@services. 'Equality@of@financial. integ ati0nof@hepr0 町a Ⅲ ト. ， C00 ぴ rah0n 皿 dincen而 esfor the 帥 en 麒 h0fthehea 皿 c打 e in甜 mu0n 皿 dfor 山 Ⅱ nn0vative hea ℡ c打 ep0 Ⅱ cy0f Ⅲ es ぬ te andmunicip団 minis ㎡ es.. andCon け aCtsWl血 pnvate. "Co0 ド ra Ⅱ onandincen廿 Vef0r h。 。 ㌔。「。 ""ロ 。 fM 。。"p,l Hea Ⅱ h. *Decision@of@clear@crite Ⅰ a@for resources di tribu on@of@federal@resources. dis ㎡ bu れ on. *Organize@the@publc@services *Oversee@the@inequ3iies. *Clear@cr@eria@for@approp Ⅱ aton. of@federal,@state@and@municipal. ・. "Bu Ⅱ d 田 eincen血 e㎡ 0rthe. 仁. n. State. ・・. *Ks ぬ bbⅡ sshⅡ .s 甘 ate 臼 ees ㎝ d re 糾 latlons. Ⅰ. *Nation3@ priorit@ s@and@criterion of 丘 n皿 cia@dis㎡ bu れ 0n. ServlCeSlfnecess ㎝Ⅳ. poliy‖reas‖nd［uni ipalii. s. 鯛 urce:De 飴 ㎎a,R R (2㏄ 2),P.42. 4@ Coordi. ati n,@Reg. Fede al. Ⅱ. *C0ordlnaⅡ onandregula. 廿. 0n0f. C00rd@na血 onaⅡ dregula. municipal@system. 「. "A"@c Ⅱ la Ⅰ 0n0fI. Ⅱ. 0n0f. Es 担 bllsh 廿@e. Ⅱ. ブ. a廿 On. COOPera. Ⅱ. 0Wofreference. *C0operateW@@hthe0tl@e munlClpaⅡⅡ eS. *Decide@the@o Ⅱ entation@of@a@. "Implementa Ⅱ on0fcen. regulations@of@SUS. re Ⅲ. 臼a. Ⅱ. 甘 al. 正. Ⅰ. Ⅰ. *Strategic@ac@ons. 0Ⅱで eference. pubic 皿 dpnvatepro. れ. onal@cases. cn0f. 鯛 urce. ㎡ dders. system. *Eval. Ev3uate@the@national@policy. ation@of@the@mu Ⅱ cipal. poli y@outcomes. outcomes. ヒ u ㏄e:De. 舖雌 ， RR.(2. *Con 廿 zact,adminis 比 aate, Ⅲ c打 e. 山 e №Ⅱ 笏， R R (2 ㏄2),P.43. implementation@of@mun@ip3. esvstem. *Adminis 甘 aⅡ 0nofheal@h. c町 eunils. *Service@provided@in@the ㎝@d ヒま n@heheal case@of@lack@of@municipal professionals. 0nmechan,sm ， Regulatlon⑪ devalua. Sa. *Exception@@cases. ア. SVstem. 'Ev3uate@the@implementation@of *@EvaluaLon@of@the. Ⅰ. @Strategic@areas. ' m 。。l。 lp"l. Ⅴ ders. State "Excep. 。 。，. 0n. Di ect@Ser Ⅴ ce@Pro. Ⅰ. 'Integration@of@service@nets. ，A nl 「．uね廿 Onof № 捷 「． s榛佗. 5@. Fede al. gional@reference. Ⅰ. Tab@@. n. Municipal. / e c e ， 回 ssem. safesl,sfem. COOPe. ati ns,@and@Evauati. State. ア. Mun@ip3. № urce:De 飴 ㎎ a,R R (2㏄2),P.42. Tab@@. 83. Ⅱ. Ⅱ. 丁. 3@ Fi c@@ Rel ti. Federal. 'Ident@y@the@probl ms@and deciion@of@prio ty@for@the muni ip3ities. (225). ㏄ 2),P.43. addit@ n@to@supplementary@procedures@to@control@and@evaluate@the@health@care@services. ， As@the@Ministry@of@Health. at@the@national@levC,@the@state@@@ responSble@for@overseCng@the@reduction@of@inequ6ity@wihin@the@states. ・. More. important ， the@state@par@cipates@@@ the@p0icy@form ℡ ation@of@the@national@health@care@system@as@a@member@of@the Ⅰ. Tripartisan@Counsel@(De@Souza. ， 2002). 4.3.1.3@ The@Secretary@of@Municipal@Health The@Secretary@of@MuniCp3@ Hea h@@@ responsible@for@an8yzing@the@necesSty@of@health@care@serVces@and@for Ⅰ. carrying@out@8l@plans@and@pr0ects@concerning@loc8@ with@private@health@care@providers,@and@establi. hea h@care@serVces Ⅰ. h@coordina. health@care@service@is@insufficient@for@the@needs@of@patents. Ⅰ. ・. ・. Moreover,@@@ needs@to@m3nt8n@contract. on@w@h@the@federal@government@in@case@the@pub The@most@cruCal@role@of@the@muni. Ⅰ. c. ipal@health@care. adminitration@@@ to@make@sure@that@peopin@the@muniCpality@have@proper@access@to@8l@hea h@care@ser Ⅴ ces ． The Secretary@of@Muniip3@Hea h@participates@in@the@region3@ hea h@care@plan@with@the@State@Secretary@of@Health@in@a h@care@services@useful@for@reSdents@in@the@muni ip8i@es， In@the@poliy way@that@@@w@l@receive@informaLon@on@hea Ⅰ. Ⅰ. Ⅰ. Ⅰ. Ⅰ. formu % 4. Ⅰ. tion@process,@the@muniip3ities@parti ipate@in@the@Bipartisan@and@Tripartisan@Counci Ⅰ. Administrativefunctions. of》he. SUS. When@making@health@care@policy,@each@government@has@its@own@important@functions@and@focuses@is@o priorities@and@needs@of@is@reSdents@w@hin@each@sphere. ， In@an@interVew@wih@the@coordinator@for@poli. of@the@State@Secretary@of@Heah@of@Ceara@mentioned@that@the@state@concentrates@on@promo Ⅰ. Ⅰ. y@speC3i. ts. ng@the@regi nali ation.
(16) (226). 84. 第 10 巻第 2 号 (2005年 8 月 ). 横浜国際社会科学研究. Table@6@ Brazilian@National@Budget@for@Health@Expenditure@in@2000 Federal. Municipal. State. Expendltu e 山ⅡⅢ 0nR$) ア. Pe. 「. capi ぬ. Per@ cap@. EXpend Ⅱ ure (如 lillionR$). Total. Expenditure (M ㎜0nRS). Expenditure@ (Million@R$)@. Pe 「 CaPl ぬ. Per capita. 20,351,[email protected]%@. 119,86@ 6,313,436@ 18.56%@. 37,18@ 7,347,[email protected]%@ 43,80@. 34,012,089@ 200,84. N0 れ h. 1,285,518@. 53.15%. 99,65. 821,830. 33.98%@. 63,70@. Northeast@. 4,582,914@. 66.94%. 95.99. 1,259,051. 18.39%. Southeast@. 8,074,371@. 51.70%@. 111,51. 2,977,387. 2,623,004@. 59.62%@. 104,47. Central@west@ 1.233,181@. 56.63%@. 105.97. Brazil. South. Source:@http://portal. saude. ・. ・. 311,096@. 12.86%@. 24,11. 2,418,444@. 187,47. 26,37. 1,004,070. 14.67%. 21,03. 6,846,035. 143,40. 19.06%. 41,12. 4,566,409. 29.24%. 63,06. 15,618,167. 215,68. 718,744. 16.34%@. 28,63@. 1,057,621@. 24.04%@. 42,12. 4,399,368@. 175,22. 536,424. 24.63%@. 46,10@. 407,964@. 18.73%@. 42,56. 2,177,569. 194,63. gov ， br/saude/aplicacoes/anuario2001/recfin/Mrecfint08.cfm. ，. by@dividing@the@muni ipaii s@into@macro-region@and@mi ro-regions@and@focuses@on@spreading@the@system@of medi 3@ serVces@among@the@muni. ip3iies ，. ResponSbilities@for@finanC8@ resource@3loca. Ⅰ. on@are@wih@the@feder8@government. ・. The@state@government@has. the@authority@of@overseeing@the@a ocation@of@HTnanC3@ resources@of@muni ip3@ government. ， Three@levels@of. Ⅰ. government@have@focused@on@the@ev3uaton@of@po muni. ip3@ coopera. Ⅰ. on. It@ very@Cear@that@the@muni Ⅰ. ・. Ⅰ. cy@outcomes@and@have@estab ip3@ government@@@. Ⅰ. shed@inter-state@and@inter-. in@charge@of@the@proVding@diect@healh. care@services@as@shown@in@the@table@5. 4.5@ Health@Care@Expenditures@in@Brazil 4.5.1@ Intergovernmental@Fiscal@Relations@on@Health@Care@Policy@in@Brazil. Health@care@expenditure@increased@from@R$23,581@million@in@2000@to@R$24,737@million@in@2002.@ The@federal government@expendiure@@@. about@60@percent@and@the@state@government@expendiure@conSsts@of@18@percent. Moreover,@the@muniCp3@government@expendiure@@@ 20@percent@of@the@tot3@health@expendiure， In@BraZl,@5560@muni. ip8@ governments@are@catego. Ⅱ. zed@into@two@systemS@the@BaSc@Hea. Ⅰ. h@Care@System@and. the@ComPete@Health@Care@System@based@on@the@capacity@of@their@health@care@services. Muni ip3ities@qu8ified@w@h@the@provi ion@of@hea h@care@services@recCve@the@@financi3@resources@direcy from@the@feder3@ government Th@@ diect@transfer@of@resources@from@the@federal@government@to@the@muni ip8 government@@@ ca ed@"from@fund@to@fund"After@recei ing@the@finanC3@ support@from@the@feder3@ government, ed@to@8locate@18@percent@of@the@fund@to@the@hea h@care@program 、 In@this@way,@the@feder3 muni ip3ii s@are@requ Ⅰ. Ⅰ. ・. Ⅰ. ・. Ⅰ. Ⅰ. government@can@exert@pressure@on@muni ip3@governments@on@how@to@use@the@fund ， For@the@baSc@heah@care,@the total@transfer@@@ calcu ted@by@per@capia For@instance,@RS@12@per@capia@annu3ly@is@transferred@to@the@muni ip3 Ⅰ. Ⅰ. government. ・. ， As@for@the@advanced@health@care@servi. es,@hospi3@ fees@are@p3d@based@on@pertinent@estimates. Muni ip3ities@categorized@as@the@baSc@health@care@p n@receive@the@transfers@from@the@government@for@baSc Ⅰ. health@services@ (De@Souza ， 2002) ，. However ， they@will@directly@receive@payment@for@having@specialized@services. from@the@state@government@when@the@state@government@is@categorized@as@advanced@hea capaci es Ⅰ. ・. The@muniCp8iies@catego. Ⅱ. zed@as@comp. Ⅰ. government@for@both@baSc@and@speC3ized@health@care@servi. Ⅰ. h@care@admini trative. te@health@care@plans@recCve@transfers@from@the@feder3 es@(De@Souza,@2002) ，. Although@the@state@government@weakened@its@control@over@the@financi. l@transfers@to@the@municipali es,@@@has Ⅰ. g3ned@control@over@the@monio ng@of@finanC3@spending ， The@ra o@of@the@"from@fund@to@fund"@ has@been increasing@Snce@1997@and@as@of@2001@ 8most@60@percent@of@the@fund@W8s@transferred@from@the@feder8@ to@the Ⅱ. Ⅰ.
(17) The@WCfare@State@and@He8th@P0iy@ (Kazumi@Noguch). (227). 85. Tab@@ 7@ Direct@Transfer@from@the@Feder8@ Government@to@Muni i G@ Governments@(Milli n@R$) 94@. 95@. l". 2". 3". Transfer@based@on@service@provided@5,158@ 5,563@ 5,275@ 5,875@ 5,087@ 5,439@ 3,603@. 3,603@. 3,928@. 4,082. From@Fund@to@Fund@(Di ect@transfer from@the@federal@government@to@the@ _@. 8,422@. 9,366@ 10,664. 567@. 96@. 97@. 98@. 99@. 0*. 1,429@ 2,327@ 4,534@ 5,903@ 7,597@. municipal@government) Tot@@ of@transfer@of@fund. 6,130@ 6,704@ 8,202@ 9,621@ 11,342@ 11,200@ 12,025@ 13,294@ 14,746. Percentage@of@Fund@to@Fund. 9%@. Source:@Ministerio@da@Saude@. muni. i al@government,@whi. (2000) ，. p ， l3.@. 21%@. 28%@. 47%@. 52%@. 67%@. 70%@. 70%@. 72%. *@(projection@from@2000@to@2003). h@shows@that@the@verti3@ re ti nsh@@ between@the@feder@@ and@muni Ⅰ. i al@government. is@very@Sgnificant@in@hea h@care@financil@relations@in@BraZl ， Ⅰ. The@total@amount@of@funds@flowing@from@the@federal@government@to@the@municipalities@through@direct@transfer. ，. increased@from@R$@6,839,189@in@2000@to@R$@7,910201@in@2001.@ Moreover ， the@total@amount@of@funds@transferred@to states@increased@from@R$@1,226,220@in@2000@to@R$@1,937,462@in@2001@(Ministerio@da@Saude@2000). 4.6@ Emergence@of@a@New@Actor The@non-government6@ organizations@(NGOs)@ in@BraZl@have@been@a@newly@emerging@actor@in@imp menting Ⅰ. soC3@ poli i s,@espeCally@regarding@hea. Ⅰ. h@policy. ・. The@devCopment@of@BraZ. Ⅰ. an@third@sector8@has@been@very. intense. 4.6.1@ History@of@the@Third@Sector@in@Brazil Going@back@to@the@coloni. l@era,@a organi aLons@establi hed@in@BraZl@for@social@we Ⅰ. are,@health,@educa on, Ⅰ. Ⅰ. and@leisure@have@been@supported@by@the@Catholic@Church@whi h@was@backed@by@the@Portuguese@crown@ (Landm 1997). For@instance ， the@Brotherhood@of@Mercy@was@responsible@for@the@first@hospitals@and@is@still@among@the. ・. leaders@of@non-profit@initiaves@in@BraZlian@soCety Ⅰ. ・. At@the@end@of@the@19@H@century ， the@first@trade@uni ns@emerged@and@the@members@of@the@trade@unions@had@the priV. Ⅰ. ge@of@recCving@medic3@. care,@as@wCl@as@assistance@in@cases@of@unemployment,@di. abiliy,@or@death Du ・. Ⅱ. ng. ， professional@associations@linked@to@the@middle@class@were@established. this@time. Du. Ⅱ. ng@the@Vargas@regime,@the@centr3@ government@intervened@in@the@society@and@economy,@controlling@trade. unions@and@soCal@welfare@services admini traLvCy. government…ontroled》hese organi. The…entr3. aⅠ. ons｝o. Ⅰ. tic3. and. ・. During@the@miiary@era,@the@Catholic@Church@stood@against@the@mil ary@regime@and@p yed@an@important@ro Ⅰ. Ⅰ. Ⅰ. in@the@development@of@secular@movements@of@workers,@laborers,@and@professionals,@and@residents@of@the@poor nCghborhoods@that@created@a@vast@new@fiCd@of@associa. Ⅰ. ons ，. More@recen. Ⅰ. y,@in@the@1990， s,@Cvil@organizations@in. BraZl@developed@rapidly@and@now@inCude@the@i sues@of@the@women's,@anti-racit,@envionment,@and@indigenous people. Even@in@the@health@ sector,@ NGOs@have@developed@in@. state,@ and@in@muni. interna on3@ and@loc3@ health@NGos@have@been@planned@by@important@roles@in@ser Ⅰ. have@not@had@previous@access@to@hea low@income@famii. s@has@been@p. He3th@ and@ SoC3@ Deve. Ⅰ. Ⅰ. Ⅰ. h@serv@ es. ・. Especia y,@the@HIV/AIDS@preven. nned@by@a@loc3@ NGO@. pment@ (ISDS. Ⅰ. Ⅰ. Ⅰ. ce@dCi ery@for@the@poor@who. Ⅴ Ⅰ. on@program@for@youths@from. such@as@the@Institute@of@Pr0ects@and@Inves. '@and@ BEMFAM10'. Pathfinder12'@have@been@supporting@the@finance@of@these@programs. ipa ties@in@BraZl ， In@ Ceara,. ． Internati nal@NGos@. Ⅰ. ga. such@ as@PoMMAR1"@. Ⅰ. ons@in and.
(18) (228). 86. 第 10巻第 2 号 (2005 年 8 月 ). 横浜国際社会科学研究. @ surance，overage｜y〕 come；roups. Table・. Not@covered@by. Total. 157,681,526. Fami@@icome@Casses. %. %. private”eath｝ln Covered｜y. 119,032,323. 38,595,206*. 15,242,118. 14,847,647@. 97.41%. More@than@1@to@2@mi imum@wages. 24,984,005. 23,768,495@. 95.13%. 1,207,310@. 4.83%. More@than@2@to@3@minimum@wages. 20,389,819. 18,470,691@. 90.59%. 1,909,288. 9.36%. More@than@3@to@5@mi. 30,138,777. 24,532,830@. 81.40%. 31,492,454. 20,549,643@. 65.25%. 10,935,038. 34.72%. 7,772,126. 45.93%. 9,144,361. 54.03%. 10,135,732. 2,413,381@. 23.81%. 7,721,211@. 76.18%. 4,370,723 4,004,625. 4,090,130@ 2,587,380@. 93.58% 64.61%. 279,299@ 1,409,200@. 6.39% 35.19%. Up@to@1@. Ⅲ ni. p Ⅱ vatehealthplan. um@wage**. imum@wages. More@than@5@to@10@mi More@than@10@to@20@. More》han・. imum@wages Ⅲ ni. Ⅲ ni. 16,923,273. um@wages. um『ages. No@ income. Undeclared. 389,926@. 5,599,573@. 2.56%. 18.58%. *Including‥ependent‖nd［ain”olders. **@Minimum@wages@is@R$@260@(approximately@US$88)@a@month@as@of@May@2004.@ Minimum@wage@was@R$130@(approx@ ately U ㏄ 44)amonthasofAp. 血 1998. Source:@IBGE:@PNAD-National@Household@Sample@Survey-Brazil@1998. http://www. ， ibge ， gov ， br/english/estatistica/populacao/trabalhoerendimento/pnad98/saude/sb04_l. ． shtm. Table@9@ HeGth@Care@Access@by@Income@Groups Outpatient Pl ces》o《eek［edi a. Total@ Pharmacy@. cares. Totalfar. 下川Ⅱ. y. More@than@. 1@ to@2. Ⅲ nl. um@wages More@than@ 2@to@3. minimum@wages More@than@3@to@5. minimum@wages. 什 oriabo unlon. Ⅱ什. Ⅵ. ア. ア. 而. C@lnlC. 1,670,693. 1.49%. 9,265,139. 8.25%. 55.76%. 281,440. 2.82%. 38,464. 0.39%. 480,506. 4.82%. 17,052,638@ 330,[email protected]%@ 9,732,[email protected]%. 711,767. 4.17%. 163,633. 0.96%. 854,316. 5.01%. 14,135,317@. 900,834. 6.37%. 180,843. 1.28%. 946,857. 6.70%. 9,967,892@. 2.16%. 46,934,231. 246,820@ 2.48%@. 329,412@ 2.33%@. 41.79%. 5,557,914@. 7,653,649@. 54.15%. 21,660,385@ 486,[email protected]%@ 10,553,[email protected]%@ 2,727,[email protected]%@ 384,434@1,77%@ 1,855,[email protected]% 534,707・. More@than@10@to@20 mnium@wa@es. 257,029. 22,957,945. 12,785,011. Undecl. PO. 19.69%. 2,429,661. More@than@5@to@10 mnium@wages More@than@ 20 minimum@wa@ No@ i come. OutPatlent. Vate iCe % ente O Ceof cpnSe 0 O Ceof Ⅵ。. %. 22,116,312. 112,302,330. Up@to@1@minimum@wage*@. Center He8th. %. 8,016,863@. 2.01%. 118,352@ 1.48%. 8,015,657. 34.91%. 5,644,630・. 549,708・. 2,521,492・. 2,503,162. 19.58%. 5,562,839. 43.51%. 235,706. 1.84%. 380,789. 4.75%. 5,300,735. 66.12%. 74,056. 0.92%. 761,426. 9.50%. 1,420,010・. es. red. 3,078,049@. 45,465@ 1.48%@. 1,823,397@. 59.24%. 193,725. 6.29%. 11,620. 0.38%. 190,882. 6.20%. 2,㎝8,230. 80,941 3.06%. 713,611. 26.95%. 793,173. 29.95%. 32,229. 1.22%. 233,732. 8.83%. Source:@PNAD-National@Household@Sample@Survey-Brazil@1998. *Minimum@wages@is@R$@260@(approximately@US$88)@a@month@as@of@May@2004.@ Minimum@wage@was@R$130@(approximately@US$44). amon. 山 asofAp. Ⅲ 1998. 4.7@ Impact@of@the@Health@Reform. ， Inequality@of@Access@of@Health@Service@in@Brazil. Only@approximately@20@percent@of@the@tot3@ popu. Ⅰ. Ⅰ. on@@@ enro. Ⅰ. ed@in@private@heah@program ， 13'@Moreover,@the Ⅰ. table@shows@that@most@of@the@low@income@population@seeks@medical@care@at@health@centers At@the@high@income vC,@of@the@most@people@go@to@private@medi al@offices@that@proⅤ de@high@qu6iy@medi 3@ serv@ es@for@the@@medical ・. Ⅰ. experti e ， Regarding@the@qu8iy@of@medi. 3@. serVces,@the@gap@between@the@haves@and@have-nots@has@been@huge. ， 14'. High（ncome“roups‖pparent tend》o｜e…overed｜y｝ Ⅱvate（nsurance『hiⅠⅠ wer（ come“roups「su3 Ⅰ. Ⅰ.
(19) The@Welfare@State@and@Health@Policy@ (Kazumi@Noguchi) Tablel0. HealthCa. ァ. e. 巳く. pend. 叶u. Heath. Expenditure@Per Capita. (US$). モ sln[ ゑⅡ nAme. こ. 二. (%@of@GDP). 2001. 2001. 5.1 3.2 2.9 3.6 2.7 2.6 3.5 2.3. 4.4 4.4 3.9 1.9 3.4 2.1 1.8 2.5. on. け covered by theSUS.. ㏄ donda ぬ W. 億eauTorba. ℡ issegmen. 87. es. (%@of@GDP). Ⅰ. 舖町 ce:Madeby. Ⅰ. Private@He9th Expend Ⅱ ure. 1. 30 573 792 356 544 231 125 199. Ⅱ. canCount. Pu5@@ Heath Expend Ⅱ ure. 2001 Araentina Br Ⅱ Ch@e Colombia Mexico Peru Bolivia Guatemala. 自. (229). 村朴 Ie丘om h 坤ゾ/h ヤ mdp.o ㎎・ ・. ぬti0n 0fhigh and low incomegroupshasbecome0b. ㎡ ousphenomenon. It@appears@that@the@private@expenditures15'@of@both@Brazil@and@Argentna@are@among@the@highest@in@the@se cted Ⅰ. Latin@American@countries@and@that@the@populati insurance@than@in@other@La. Ⅰ. n@in@these@two@nations@has@been@. n@American@countries ， Based@on@available@data,@Argen. spending@more@ ㌔. on@p. Ⅱ. vate. na@spent@US$1,130@per@capia,. whi h@marked@the@hihest@among@Lat@@ American@countries,@whiBraZl@spent@$@573@per@caPta@on@he8th@care Ⅰ. Conclusion. 5. A. hough@va. Ⅰ. Ⅱ. ous@issues@related@to@de bera ve@ democra Ⅰ. Ⅰ. regionali a on@of@the@health@po Ⅰ. Ⅰ. Ⅰ. c@. systems@ such@ as@hea. Ⅰ. h@ councis@ and@the. cy@have@been@raised@as@important@points@to@be@solved,@the@most@prominent. diference@between@centralized@and@decentrali ed@health@systems@is@that@at@least@3l@ciizens@are@guaranteed@for primary@he8th@care@access@by@the@1988@Constitution Although@the@health@counC. lack@the@funcLon@of@the@polii. Ⅰ. policy@making@is@nonetheless@being@provided counC. Ⅰ. ， Current. ， the@Brazilian@health@policy@is@fiscal centralized. Ⅰ. Ⅰ. 3@. institu ons,@a@place@for@the@dicusSon@of@hea Ⅰ. Ⅰ. h. ， The@characteristics@of@Brazilian@federalism@show@that@health. do@function@from@regin@to@region ，. Although@the@clasSficat n@by@Espi g-Andersen@can@hard be@apPi d@to@anayze@soci3@ policy@@@developing countries,@it@is@benefiC8@ to@understand@that@the@diverSficaton@of@socio-econom@@ aspects@wi affect@the@formation policies@and@the@necessity@of@forming of@the@soC3@policies， Th@@ modC@ is@made@for@the@devCoped@nations'@soC3@ Ⅰ. Ⅰ. Ⅰ. the@models@which@analyze@the@social@policy@in@developing@countries@is@high expenditures@are@highest@among@Latin@American@nations,@it@is@dificu. Ⅰ. ， Although@Brazil ， s@private@health. to@categorize@as@a@liber8@ model ， If@thi. segmentation@continues@in@BraZl,@@@ appears@that@Bra2l@may@become@the@li eral@modC@ @@ is@health@poliy As@long@as@the@inequality@of@access@to@hea h@care@servies@perSsts,@@@ @@ hard@to@ca the@BraZli n@system@as@a Ⅰ. Ⅰ. soC3ist@poliy@although@the@. 1988@Constitu. Ⅰ. on@guarantees@univers3@. healh@care@to@3l@ci@. ens ，. In@hea h@care Ⅰ. governance,@the@NGos@have@played@a@cruC@@ role@@@fillig@the@gap@of@qu3ity@of@serv@es@between@the@haves@and haves-nots@in@BraZl At@the@feder8@ level,@in@the@recent@naton3@program,@Piano@Bras@@ para@Todos@ (Plan@for ・. everyone@in@Brazil),@the@he3th@care@program@has@been@among@th@@. program. ・. The@author@of@this@paper@conducted@a@fiCd@research@in@Ceara,@BraZl@and@in@the@future@plans@to@publish@a@ study@of@a@role@of@culture@in@publ@@management@in@Ceara.
(20) 88. (230). 横浜国際社会科学研究. 第 10巻第 2 号 (2005年 8 月 ). Appendix@1@ Capacity@of@the@Brazilian@Municipalities. Appendix@2@ Municipal@Councils. ㎝笏 (2 ㏄2),P.26. Source:DeS. Source:@IBGE. ， Diretoria@de@Pesquisas. ， Coordenacao. de@Popula@ao@e@Indicadores@Socials ， Pesquisa@de Idomag ㏄ sB ゑsi㏄ sM ㎡ cip㎡s2 ㏄ 1. Notes. 1)@See@Appendix@1. 2)@Brazilian@Real=0.39200@US@Dollar@as@of@April@22 ， 2005 3)@Ceara@is@a@state@located@in@Northeastern@Brazil 4)@PAB@is@basic@package@of@services 5)SeeAppend. ， where@the@author@conducted@research@for@this@case@study@in@June. ， PAB-A@is@the@expanded@basic@package@of@services. ， 2004. ，. 注2. 6)@Maranguape@is@a@municipality@of@Ceara ， Brazil， where@the@author@conducted@research@for@this@case@study@in@June ， 2004 7)@Mu Ⅰ ci 3ities@in@Ceara@receie@fund@from@the@feder3@and@state@government@to@pay@for@the@sa ry@for@commuHty@health Ⅰ. agents. ・. 8)@The@third@sectors@in@Brazil@include@associations ， philanthropic ， benefit@or@charity-related@organizations ， nongovernmental@organizations. 9)@ISDS@was@founded@in@May. ， and@foundations. ， 1993@and@a@non-governmental@organization@in@Fortaleza ， Ceara. improvement@of@the@health@of@population@and@focuses@on@problem@of@public@health@and@social@development. 10)@BEMFAM@@@. a@non ，government3@. ・. It@contributes@to@the ，. organiza on@that@promotes@reproducLve@rights@as@a@fundament3@ human@right ， Through@health@and@educational@services@in@sexuality@and@reproductive@health ， BEMFAM@uses@participatory@methods Ⅰ. and“roup‥ynamics《upported｜y《pecialized‘ducational‖nd（nformative［aterials ， The｝artnership『ith.
図
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