Descrição
The paper constructs an interpretation for the dual institutional configuration of health care in Brazil, characterized by the coexistence of a public sector and another private one, although, formally, health policy since the 1988 Constitution ensures free and universal access to the public system. Using the analytical arguments of new historical institutionalism, this interpretation views prior health policies as a main explanatory factor, stemming from the related notions of policy feedback and path dependence, manifested in lock-in effects and learning effects. The central argument is that while this institutional arrangement is the result of choices made at different inflection points in health policy, they were constrained by the institutional effects of earlier choices including the very structure of the health policy arena, given that past policies contributed to the formation of different actors and interests, arising from the incentives and benefits accorded. As a result of the effects of the legacy of earlier policies, health reform as defined in the 1988 Constitution was a process of limited innovation, characterized both by a disruption, in formal-law terms, of the norms of regulated and segmented citizenship and by elements of continuity. This duplicity is expressed in the constitutional text itself, is concretized by the entrenchment of the hybrid model of care, and is consolidated with the regulation of private care in the late 1990s, concurrent with the deployment of the public system. Beyond not being discontinuous, this change institutionalized the dual path.||The paper constructs an interpretation for the dual institutional configuration of health care in Brazil, characterized by the coexistence of a public sector and another private one, although, formally, health policy since the 1988 Constitution ensures free and universal access to the public system. Using the analytical arguments of new historical institutionalism, this interpretation views prior health policies as a main explanatory factor, stemming from the related notions of policy feedback and path dependence, manifested in lock-in effects and learning effects. The central argument is that while this institutional arrangement is the result of choices made at different inflection points in health policy, they were constrained by the institutional effects of earlier choices including the very structure of the health policy arena, given that past policies contributed to the formation of different actors and interests, arising from the incentives and benefits accorded. As a result of the effects of the legacy of earlier policies, health reform as defined in the 1988 Constitution was a process of limited innovation, characterized both by a disruption, in formal-law terms, of the norms of regulated and segmented citizenship and by elements of continuity. This duplicity is expressed in the constitutional text itself, is concretized by the entrenchment of the hybrid model of care, and is consolidated with the regulation of private care in the late 1990s, concurrent with the deployment of the public system. Beyond not being discontinuous, this change institutionalized the dual path.||O artigo constrói uma interpretação para a configuração institucional dual da assistência à saúde no Brasil, caracterizada pela coexistência de um segmento público e outro privado, apesar de, formalmente, a política de saúde desde a Constituição de 1988 garantir o acesso gratuito e universal ao sistema público. Utilizando-se dos argumentos analíticos do novo institucionalismo histórico, essa interpretação considera como fator explicativo principal as políticas de saúde prévias a partir das noções correlatas de policy feedback e dependência de trajetória, traduzidas nos efeitos lock-in e nos efeitos de aprendizagem. O argumento central é que, embora esse arranjo institucional seja resultado de escolhas realizadas em diferentes momentos de inflexão da política de saúde, essas foram constrangidas pelos efeitos institucionais das escolhas anteriores os quais incluem a própria conformação da arena política da saúde dado que políticas anteriores contribuíram para a constituição de diferentes atores e interesses, a partir dos incentivos e benefícios concedidos. Em consequência dos efeitos do legado das políticas prévias, a reforma sanitária definida na Constituição de 1988 foi um processo de inovação limitada, caracterizado tanto por uma ruptura em termos jurídico-formais do padrão de cidadania regulada e segmentada como por elementos de continuidade. Essa duplicidade se expressa no próprio texto constitucional, se concretiza pelo aprofundamento das características do modelo híbrido da assistência e se consolida com a regulação da assistência privada no final dos anos 90 concomitantemente àimplantação do sistema público. Além de não ser descontínua, a mudança institucionalizou a dupla trajetória.
