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合同订立与账目呈报模式。本研究采用质性研究方法，数据来源涵盖合同文件、季度管理报告、对该州医院护理高级管理人员的访谈，以及基于国家卫生机构登记册梳理的医院基本特征。在概念层面，本研究采用问责制与绩效评估框架，并结合公共政策循环模型开展分析。相关社会组织编制的预算分为固定与变动两部分，且与绩效直接挂钩；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法依据。研究显示，合同目标与当地卫生需求之间的相关性极低，这一现象尤为突出。合同附加条款虽对医院床位扩容至关重要，但未能满足新增人力资源的需求，同时也给预算再平衡能力带来了重大挑战。此外，在技术架构的监测与管控方法层面，由于指标体系不完善，且报告中对医院绩效的批判性分析尚处于起步阶段，可见存在显著的运行脆弱性。本研究认为，该以新管理主义视角为理论基础的模式，在推行过程中未同步完善监测体系——这正是国家合同缔约权所面临的戈尔迪之结（Gordian knot）。