The main brand of state health in almost three decades of PSDB government in São Paulo, the OSS (social health organizations) today consume a quarter of the portfolio’s budget, had the model exported to other Brazilian statesbut continue to be the target of investigations for alleged irregularities.
These private non-profit organizations began to act in the THEIR from São Paulo since 1998, in the same year they were created by federal law. The government defines and plans the public policies to be adopted by the OSS, in addition to production and quality targets. And you have to monitor them and demand the results defined in the contract.
Currently, there are 138 state health services being managed by OSS, including hospitals, specialty outpatient clinics, rehabilitation units and specialized drug pharmacies.
In 2013, these organizations consumed BRL 3.15 billion out of a budget of BRL 16.6 billion (18.9%). In 2019, that share increased. It accounted for 24.3% of the budget (R$5.67 billion out of a total of R$23.3 billion), according to data from the Transparency Portal.
Studies by the State Department of Health of São Paulo point out that hospitals managed by OSS are up to 52% more productive and cost 32% less than those under direct administration. However, the model is considered not very transparent and has already undergone several investigations, which culminated in a state CPI in 2018.
Last October, a blitz by the TCE (Sao Paulo State Court of Auditors) in 273 hospitals/health units in São Paulo, managed by OSS, found various types of irregularities. Among them, expired drugs (in 13% of the inspected units), doctors absent from their jobs (12%) and broken or disused diagnostic equipment (31%).
Previous reports from the São Paulo TCE pointed to other problems such as non-compliance with established goals, insufficient number of doctors and disrespecting work schedules, in addition to corruption allegations.
“The OSS are the trademark of the PSDB, they consume the largest amount of money from the state secretariat, but there is a lack of a great evaluation of the whole. Some studies point to greater economic efficiency, better management of human resources, but there are many problems and impasses”, he says. Mario Scheffer, professor at USP’s preventive medicine department and researcher on the subject.
Rudi Rocha, professor at FGV, director of research at Ieps (Institute of Studies for Health Policies) and coordinator of a study that evaluated OSS in hospitals in São Paulo, points to the lack of transparency as one of the model’s major problems. “The biggest challenge for us [durante o estudo] went to pick up the contracts. It’s a very serious matter.”
According to him, although there are positive evaluations on the performance of organizations, from the point of view of scientific evidence, it is still not known what the real cost-effectiveness of the model is.
Scheffer agrees and adds that, with the OSS, there is a lot of fragmentation of information, for example, about human resources in the state network. “We still can’t judge this management modality by its performance, by the quality of care. Is it possible, with the resources they receive today, for the OSS to deliver more? We don’t know.”
In a note, the Secretary of State for Health says that the OSS reduced bureaucracy and streamlined the implementation of new units and the hiring of human resources. In addition, says the folder, the services administered by the OSS have more than 95% approval from the population.
For the physician Ana Maria Malik, coordinator of FGV Saúde, there was organizational learning by the Secretary of State for Health in the evaluation and control of contracts with the OSS, however, this does not prevent non-compliance with what was agreed. “But in São Paulo this is even better than in the rest of the country.”
At the same time that the management of SUS services has become more private over these almost 30 years, the private hospital network (which serves plans and individuals) has also grown, and the public network has shrunkaccording to data from Datasus.
In 2005, for example, the state had 96,761 inpatient beds overall, of which 64,563 were SUS and 32,198 were non-SUS. In October 2022, there were 94,064 hospital beds in general, with 54,952 from SUS and 39,112 from non-SUS. That is, there was a 15% drop in SUS beds and a 21.4% increase in private beds.
In the same period, the rate of São Paulo with health plans jumped from 37% (13.8 million) to 43% (18 million). In the capital of São Paulo, over 50% of the population has a health plan with medical coverage. In the country as a whole, 26%.
One of the reflections of the reduction of SUS beds in the state of São Paulo is the queues for medium and high complexity surgeries, which got worse with the pandemic🇧🇷 Earlier this year, around 540,000 people were awaiting surgery. With joint efforts and agreements with private services, there was a 52% reduction in the queue until September, according to the State Health Secretariat.
In a note, the folder says that, in these 28 years of PSDB management, medium and high complexity care has been reinforced by 43 new state hospitals, 22 in Greater São Paulo and 21 in the interior and coast. Among them is the Cancer Institute of São Paulo (Icesp), the largest cancer hospital in Latin America. “Before 1995, the state had 15 skeletons of hospitals with unfinished works, which were all completed over those years”, says the folder.
The secretariat also cites the creation of 62 Ames (Specialty Doctors Outpatient Clinics) and 20 units of the Lucy Montoro Rehabilitation Network, and the Hebe Camargo Cancer Fighting Network, with 95 comprehensive oncology care centers in all regions of the state. The institutions, according to the portfolio, have expanded the capacity of the SUS and reduced waiting times and queues in hospitals.
The entire offer of medium and high complexity services in the state, in addition to emergency cases, is regulated by Cross (Health Services Offer Regulation Center), an online system that operates 24 hours a day.
For physician Ana Maria Malik, coordinator of FGV Saúde, although there are queues, there has been progress in access to medium and high complexity care with the creation of Cross. “Thinking about São Paulo, in Brazil, the offer will always be insufficient, but it’s better with Cross than without Cross.”
IMPROVEMENT IN INDICATORS
In these almost 30 years, some health indicators in the state of São Paulo have taken great positive leaps. AIDS mortality, for example, has dropped 78% since 1995, when the peak of deaths from the disease occurred.
In the same period, the infant mortality rate (IMR) dropped by 61%. Although the downward trend occurs throughout the state, regional disparities still persist.
In 2020, the IMR in the state was 9.75 deaths of children under one year old per thousand live births, the first time in history that it reached a single digit level. But while the region of São José do Rio Preto recorded a rate of 7.79, that of Baixada Santista was 11.1.
According to epidemiologist Paulo Menezes, a professor at USP and who has already coordinated the state department’s health surveillance, the Baixada Santista region concentrates a large proportion of vulnerable people. “Almost 50% of the population lives in communities. The infant and maternal mortality indicators are always among the worst in the state.”
These health indicators, in addition to social determinants, are very sensitive to primary care, which is the responsibility of municipalities. “The challenge of greater integration between the municipalities remains”, says Menezes.
One of the obstacles is the political pressure that exists in the appointment of regional health coordinators, which does not follow technical criteria. “This is a major obstacle to change, to seek solutions to reduce these disparities.”
