Financing and controllership of municipalities in the State of São Paulo in the health area: an evaluation of efficiency / Financiamento e controladoria dos municípios paulistas no setor saúde: uma avaliação de eficiência

AUTOR(ES)
DATA DE PUBLICAÇÃO

2008

RESUMO

Sistema Único de Saúde (SUS)1 is characterized by complex intergovernmental relationships that have granted continuing enhancement in the solution of issues related to public health service rendering to the population. While a governmental sector policy, SUS is influenced by recent efforts in the distribution and performance of the principles of public administration management, whose focus is management centered on both results, and the efficient use of resources. Within this context, the evaluation of performance becomes more prominent; however, the definition of evaluation parameters by the Public Management Controllership has been no easy task, because the type of control applicable to public sector activities depends on four complex criteria: ambiguity of objectives; output measurement; knowledge of effects of intervention, and recurrence of activities. One alternative to circumvent the difficulties with the evaluation of performance is doing it through benchmark. Thus, this study aimed at raising, measuring, and explaining the variations in performance in the municipalities in the State of São Paulo regarding the economic efficiency in the use of public funds in the public health basic actions as related to profile of expenditure financing in such area. Economic efficiency reflects the capability of an entity to obtain maximum output at the lowest cost, and was measured by means of Data Envelopment Analysis (DEA): a technique of optimization based on linear programming and designed to establish the measurement of relative efficiency among different decision making units. In its turn, economic efficiency, a parameter of evaluation of public sector performance, is influenced by the way the legislature and bureaucrats deal with budget constraints. The literature on federalism predicts that non-matching unconditional transfers lead to public expenses with waste, brought about by the process of fiscal illusion, by the reduction of trade off power, and/or the softening of budget constraints. In the first stage of the DEA Model, efficiency scores were calculated based on paid out expenses with basic health procedures and the quantity of direct output produced by such sub function. The results pointed out that only 17 out of 599 municipalities in the State of São Paulo under analysis were considered efficient, and that it was possible to raise the quantity of services rendered to the population considerably without the need of other budget grants. In the second stage of the DEA Model, it was possible to notice that the proportion of old people in a jurisdiction causes service rendering to be more expensive; also, higher population concentration, degree of urbanization and level of health facilities favor public expenses with efficiency. These four variables are not under the control of the public manager; therefore, efficiency scores were adjusted to reflect the performance resulting from the discretionary power. Through these adjusted efficiency scores, and by means of a regression analysis it was possible to see that non-matching unconditional transfers increase the inefficiency in public expenditure with basic health procedures, as envisaged in the literature. On the other hand, grants received from SUS, both conditional and unconditional, decrease inefficiency, which indicates improvement reached by the management of SUS. Another factor bearing positive interdependence with efficiency is the schooling index, which shows that a population with higher schooling indices may better the evaluation of performance and accountability. This work may be expanded to other sub functions in the health and even government area and may be deepened as far as quality goes. Besides, longitudinal studies might help distinguish the effect of the process of fiscal illusion and of the reduction in trade off power relating to the softening of budget constraint stemming from the possibility of financial help come from other government tiers. We believe this study has contributed to the suggestion of possibilities and restrictions of comparative evaluations in the public sector. 1 public health system

ASSUNTO(S)

controllership eficiência do serviço público política de saúde efficiency of public service health policy controladoria federalism federalismo

ACESSO AO ARTIGO

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