Decentralisation of pharmaceutical assistance in Brazil: Impacts on access to medicines

Abstract

This thesis explores how decentralisation of basic pharmaceutical assistance was introduced in Brazil. Decentralisation aimed to improve access to basic medicines. Nevertheless, the inconsistency in the availability of medicines in the Brazilian public health system (SUS - Unified Health System) justified the development of two seemingly contradictory, yet co-existing, approaches: decentralisation and recentralisation. The central question of my thesis was how the simultaneous processes of decentralisation and recentralisation, which took place between 1998 and 2011, have affected access to medicines distributed by SUS. My second aim was to explore how political and power dynamics impacted the implementation of decentralisation policies. I carried out semi-structured interviews with key actors in policy-making for pharmaceutical assistance; interviewees were selected from among the health secretaries and Ministry of Health officials that participated in interfederative boards of agreement. The Grounded Theory approach, as well as documentary analysis, informed my data collection and analysis. My findings suggest that decentralisation was important for improving the availability of medicines, although levels of improvement varied across the country. Decentralisation in itself was not sufficient to improve the availability of medicines largely due to the regional differences. Federative relationships involved in the decentralised management of pharmaceutical assistance are seen as important by health secretaries, but are considered laborious and time-consuming by Ministry of Health officials. Lack of compliance with agreements at state level was mentioned as one of the main barriers to further improving access to medicines. In this context of struggle, the Popular Pharmacy programme, controlled by the federal government, was created in 2004. The initiative, which can be regarded as a recentralisation process, rapidly improved the availability of basic medicines. There is no clear indication of which is the best approach for improving access to basic medicines in Brazil. Both decentralisation and centralisation worked well in some contexts but failed in others.