Indirect management in hospital care: analysis of contractualisation by outsourcing of SUS hospitals

ABSTRACT The purpose of this study was to analyze contracting and rendering of accounts adopted in the publicity of hospital services in the Unified Health System (SUS) Bahia. Qualitative research, based on contracts, quarterly management reports, interviews with senior management of hospital care in the state, and hospital characteristics according to the National Register of Health Establishments. Conceptually, accountability and performance were adopted, with implementation of the Cycle of Public Policy. The Social Organizations presented a budget consisting of fixed and variable parts that is conditioned to performance, its management and assistance indicators are pre-established and the goals plan justifies the occurrence of budget cuts and/or rebalancing. The low correlation between contractual goals and health needs of the territory was striking. The contractual additives were essential for expansion of hospital beds, but did not meet the need for more human resources and determined an important challenge for the capacity of budgetary rebalancing. Moreover on the methodology of monitoring and control of the technostructure, a remarkable fragility was observed, given the insufficiency of indicators and the incipient critical analysis of the hospital performance presented in the reports. It is considered that the model, which has a doctrinaire basis in the neo-managerial perspective, was implemented without simultaneous improvement of the monitoring, Gordian knot of the contracting power of the state.

摘要：本研究旨在分析巴伊亚州统一卫生系统（Unified Health System, SUS）中医院服务公示环节所采用的契约制定与账务呈报模式。本研究为定性研究，数据来源涵盖合同文本、季度管理报告、对该州医院护理高级管理层的访谈，以及依据国家卫生机构登记册整理的医院特征信息。本研究采用问责制与绩效评价作为核心概念框架，并结合公共政策循环的实施逻辑。参与运营的社会组织所编制的预算分为固定与可变两部分，与绩效表现直接挂钩；其管理与服务指标均预先设定，目标规划可作为预算削减或预算再平衡的合理性依据。研究发现，契约设定的目标与该地区的卫生需求之间相关性极低，这一现象尤为显著。合同增补条款对病床扩容起到了关键支撑作用，但无法满足人力资源扩充的需求，同时给预算再平衡能力带来了重大挑战。此外，在技术结构的监测与控制方法层面，由于指标体系设置不完善，且报告中对医院绩效的批判性分析尚处于起步阶段，可见显著的体系脆弱性。本研究认为，这一以新管理主义为理论基础的模式在推行时未同步完善监测体系，而监测正是国家缔约权行使中的戈尔迪之结。