Decentralising the health sector: issues in Brazil

The health sector in Brazil has undergone important changes, particularly w ith the development of the Unified Health System (SUS). Decentralisation is an important principle of SUS and advances have been made in transferring responsibilities and resources to the local government units, known as muni cipios. This article describes the changes introduced, focusing on the syst em of municipio classification and the funding mechanisms introduced throug h the basic operating rule (BOR) of 1996. The paper then moves on to analys ing three key issues of decentralisation in Brazil that are related to the policy process, the system of decentralisation and the output of decentrali sation. Firstly, the formal process by which decisions on health sector ref orm are made is discussed with particular attention bring paid to the negot iated and relatively open policy space. Secondly, the role of the states is discussed within the decentralised system. Thirdly, the impact of decentra lisation on equity is discussed with particular reference to the resourcing of the Municipal Health Funds. The article concludes by emphasising the po litical nature of health sector decentralisation and the need to develop th e conditions for effectiveness in decentralisation programmes. (C) 2000 Els evier Science ireland Ltd. All rights reserved.