Constructing the "management pact" for Brazil's National Health System (SUS): from supervised decentralization to network management

Over time, the implementation of Brazil's National Health System (SUS) has encountered management problems. Initially, steadily rising pressures calling for State reform and trimmer costs affect the universal healthcare that is the purpose of this system. Conflicts then flare up between the decentralization principle and the network concept, viewed here as not merely links among different spheres of management, but rather the model through which access to a right is exercised through a network. Operating decisions on healthcare have been decentralized, while the budget transfers underwriting these decisions remain unchanged. From the civil service standpoint, the decentralization of healthcare management was halted by the issue of the Operational Healthcare Directive in January 2001. From the management standpoint, the introduction of the network concept - which is the most effective weapon against verticalizing decision structures - must deal with operating and financial bottlenecks that prevent players in different organizations from speaking the same 'language', which is the most effective way of building up inter-organizational links. Effective interaction among these languages will be attained only through constructing management pacts.