Analysis of ordinances regulating the national policy of high complexity cardiovascular care

Abstract

SPECIAL ARTICLE ICardiovascular Surgery Specialist, Master in Public Policy Evaluation-UFC, Chief of Pediatric Cardiovascular Surgery, Hospital Dr. Carlos Alberto Studart Gomes/SESA, Incor Criança, Fortaleza, CE, Brazil IIPhD, Professor of the Master in Public Policy Evaluation - Federal University of Ceará, Fortaleza, CE, Brazil IIIProfessor of the Master in Public Policy Evaluation - Federal University of Ceará, Fortaleza, CE, Brazil Correspondence Address Descriptors: Heart/surgery. Cardiac surgical procedures. Child care. Health policy. Public Health. Ministerial decrees are tools used to create, adapt or regulatory policies established from social demands. The ordinances, subject of this study, inaugurate another moment of care to patients with cardiovascular disease and all forms to the. National Policy of High-complexity Cardiovascular Care The study that follows is a chapter of dissertation: Evaluation of the National Policy of High-complexity Cardiovascular Care focusing on Pediatric Cardiovascular Surgery, held at the Federal University of Ceará in the Professional Master's Degree Course in Public Policy Evaluation. We try to analyze the concepts on which the ordinance is based, according to the principles of the Unified Health System (SUS), literature theorizes that such principles, discourses of managers and directors of companies involved in the merits and results of questionnaire applied to cardiovascular surgeons belonging to the Brazilian Society of Cardiovascular Surgery (SBCCV), the sample is calculated by reference to 778 professionals, number provided by SBCCV being distributed in April 2009, as follows: 30 (4%) in the North, 107 (14%) in the Northeast, 68 (9%) in the Midwest region, 437 (56%) and 136 in the Southeast (17%) in the South The sample size for a sampling error of e = 4.87%, was 266 surgeons. Based on this calculation, the sample by region corresponded to ten surgeons in the North, 58 in the Northeast, 25 in the Midwest, Southeast and 43 130 of the South, a total of 266 cardiovascular surgeons. In January 2003, the Ministry of Health (MS) initiated discussion about comprehensive reform to meet the high complexity and promoted intensive discussion to formulate the so-called: National Policy of High-complexity Cardiovascular Care. The various specialties were represented by their respective companies, as the Brazilian Society of Cardiology, Brazilian Society of Interventional Radiology and Vascular Surgery, Brazilian Society of Interventional Cardiology, Brazilian Society of Angiology and Vascular Surgery, Brazilian Society of Cardiac Arrhythmias and BSCVS, with its Departments of Cardiac Pacing and Department of Pediatric Cardiovascular Surgery (DCCVPed). In this scenario, disputes could be observed by medical locus of activity, performance space for hospitals and incorporation of products [1]. The MS proposed to centralize network of university hospitals in the care of high cost and decrease the number of hospitals to the private network, signaling for the development of an exclusionary policy, keeping in view the various requirements for hospitals regarding the physical structure, equipment and human resources, without adequate financial compensation [1]. The SBCCV, during this process, signaled the development of a policy that would meet the regional differences and the fact that it was impossible to meet all the requirements proposed by MS, since most services registered in cardiovascular surgery was experiencing serious financial difficulties [1]. The legal framework came on June 15, 2004 through two devices: the decree No. 1169/GM [2], which established the National Policy of High-complexity Cardiovascular Care, and Ordinance No. 210 SAS / MS [3] regulated the pediatric cardiovascular surgery. This ordinance was amended in some parameters on May 26, 2006, with the publication of the ordinance SAS / MS No 384. The decree No. 1169/GM/2004 instituted the National Policy of High-complexity Cardiovascular Care considering some requirements, listed below, who gave props to the conceptual elaboration of Ordinance No. 210 and its annexes, which are discussed below. 1. Comprehensive care to patients with cardiovascular pathologies of the Unified Health System - SUS. Integral care consists of the necessary support to those that need treatment. This concept is of great importance, given that comprehensiveness is one of the principles of the SUS. Integrality is used on an ongoing basis with reference to the guideline of integrated care as the principle of equality of care, seen as a set of actions and, preventive and curative, individual and collective health services at different levels of system complexity [4]. 2. Need to organize assistance to those patients on hierarchical and regional services, and based on the principles of universality and integrality of health. Universality is defined as access by all to all services. Integrality is the care that comprises all levels of health care, i.e., the provision of assistance. However, the ordinance of 2004 did not define how the relationship would take the three levels of care with respect to cardiology and pediatric cardiovascular surgery. In order to the principles of universality and integrality to be effective, it would be necessary to structure the specific model of care for pregnant women and the newborn as well as pediatric monitoring, i.e., the creation of a multidisciplinary care team for the primary and secondary care levels as well as capacitating institutions that provide this kind of assistance with necessary equipment for the diagnosis and monitoring of patients. It was also not established how much and from what sources would be the resources to redress these investments, in addition to determining that all units shall participate in the cardiovascular surgery program, as described in paragraph 1.4 of Annex I. As for regionalization, Annex IV of Ordinance # 210 established some parameters of territorial operation. In the case of High Complexity Care Units in Pediatric Cardiovascular Surgery, there shall be a ratio of one unit to serve 800,000 inhabitants (1:800.000), which were also adopted by defining the criteria of article eight of the same ordinance. In defining the quantitative and geographic distribution of units, such as: population to be served; need for health care coverage, access mechanisms with reference and counter reference, technical and operational services; series of visits, taking into account the pent-up demand; integration with the hospital reference network of emergency care and emergency services with prehospital care, with the High Complexity National Regulatory Central (CNRAC) and other outpatient and hospital care services available in the State. In the same article it was decided that, in the absence of any institution to perform highly complex cardiovascular procedures, the local manager should ensure their achievement by directing the patient through CNRAC. Thus, these mechanisms would be rational allocation of resources, organized on the basis of technological hierarchy disposition, seeking to expand the capacity of assistance at the entrance of the system, so that other technologies were incorporated to support the needs of each user considering economies of scale and scope. However, it is observed that it is still needed due geographical distribution of health services, human resources and programs, enabling the connection of multiple clinical knowledge and collective health to provide comprehensive care with strategies and mechanisms of articulation and appropriate referencing, sufficient to meet the health needs of specific population base [5]. The structuring of a network of regionalized health care has as its objectives the provision of continuous, integral, quality, responsible and humane health care, articulated according to the complementarity of various densities and technology organized by criteria of microeconomic efficiency in use of resources. This kind of network should be made by the planning, management and financing intergovernmental cooperative and focused on the development of integrated health policy tailored to the population needs of each singular regional space [5]. In complement to what has been defined by MS, Artmann & Rivera [6] i it understood that regionalization requires the allocation of health resources in a given area, in order to facilitate access, offer high quality services, low cost and with better fairness and faster responses to the desires and needs of consumers. The regionalization approach is proposed to find the balance between excessive centralization and complete decentralization of structural health services. The distance is one of the most important elements to establish the geographical distribution of health institutions within the regionalized system. One cannot help commenting that in a country with vast distances, huge regional differences, especially between the extremes almost depopulated regions and urban centers with overpopulation, we need to think creatively and contextualize parameters through adaptations that bring viable and positive impacts on the problematic situation. The major criterion for the case is access to treatment [6]. In the case of health care, regionalization meets the criterion of priority planning service provision and the need to rationalize the relationship of these dynamics, establishing greater coordination to achieve results in terms of access and equity adequate [6]. Regionalization of care in pediatric cardiology or collaboration among regional centers can not only improve results by focusing the expertise of qualified staff in some institutions, but also to help evaluate the quality due to the increased number of patients [7]. Related to this proposal, interviewed cardiovascular surgeons indicated the establishment of care centers for care of heart disease of higher complexity. Such centers should be distributed in various regions responsible for territorial base previously established, providing quick and skilled care, as in some diseases the delay in care can be the difference in treatment outcome and other long-term survival in patients . The ordinance in question has adopted the principle of universality, which is access, indiscriminately, of all to all services, based on regional and hierarchical attention. However, the current policy lacks an approach that aims to meet the inequities in cardiovascular care, especially in some regions. Speaking universality it is not the same thing as promoting equity. According to Bottle & Porto [8], "equality is a consequence of the equity. The recognition of differences and suppression of needs make possible the achievement of equality." Equity has been interpreted both in official discourse and in the speech of relevance social agents in the arena of health, as a principle of SUS. It is fair that this is so because the universal systems shall seek fairness [9]. According to Neves [10], equity is equal access to health care through its differentiated redistribution: giving more to those who have less and who even have the same conditions, in a regulatory action of inequalities. This is possible only by the principle of solidarity, in which all men redistribute goods among themselves. It suggests the application of two criteria in particular: the medical need, as a factor of rationalization and equal opportunities, as a factor of universal accessibility. The Standard Operating Procedure (SOP) 96 aimed to promote equity with quality and rationality in spending. In order to avoid cumulative process unfairly by some municipalities, with the increasing dispossession of others, the composition of municipal systems and ratification of agreed schedules in their health councils aimed to establishments of regional networks for increased access to quality and lower cost [11]. Annex II of Ordinance No. 210 was based on the principle of integral proposed in Ordinance No. 1169/GM, dealing with classification standards and accreditation of units in highly complex cardiovascular care. It was then determined that such units shall offer comprehensive and specialized assistance to patients with diseases of the cardiovascular system and, therefore, it was necessary to: adhere to the criteria of the National Humanization Policy; develop or participate in prevention programs and early disease detection system cardiovascular; offer diagnosis and treatment for the care of patients with disease of the cardiovascular system; develop rehabilitation programs, support and monitoring through specific procedures that promote the improvement of physical and psychological conditions of the patient, besides acting in the preoperative preparation operative or postoperative in addition towards the restoration of functional capacity. In general, the policy met the principle of completeness when encompassed in care: early diagnosis, treatment, prevention and rehabilitation. Pauli [12] divides the levels of primary prevention, which is subdivided into health promotion and specific protection; minor in diagnosis with early treatment and limitation of disability, and tertiary prevention to rehabilitation. In none of these directives that comprise the National policy there is reference to the type of action or what kind of disease the primary prevention shall be developed. The determinations merely stipulate that such activities shall be developed in coordination with programs and standards defined by various levels of management. When it comes to early diagnosis, the policy does not establish standards for adequacy of services to the attention of the segment, which begins in the care of the fetus, neonate and child. On the other hand, it would require physical structure, equipment and specialized professionals in order to such to be met. The sources of funds for the execution of several actions also represent important gap in politics. It is worth mentioning that early diagnosis points to the scheduled time and treatment in the second article of the decree No. 1169/GM determined that the Secretaries of State for Health establish regional planning and hierarchical network to form the State and / or Regional High-complexity Cardiovascular Care, in order to assist patients with diseases of the cardiovascular system that needed to be subjected to procedures classified as high complexity. As for rehabilitation, tertiary prevention and other actions to promote integrity, the ordinances do not specify the source of payment, making it infeasible adoption by providers, although these have been signed at the time of accreditation. 3. Ensuring these patients to assistance at various levels of complexity, through multidisciplinary teams, using techniques and specific therapeutic methods. This topic refers to the completeness, and its effectiveness hindered by a lack of coordination between actions at different levels, the lack of infrastructure of services provided to primary and secondary care and tertiary care deficient capacity to meet demand at that level. It is necessary to emphasize that the principle of intersectoriality shall be noted, referring to food conditions, education and leisure, pillars to ensure good cardiovascular health. 4. Need for a new conformation of State Networks and/ or Regional Networks of High-complexity Cardiovascular Care, as well as to determine their role in health care and the technical qualities necessary for the proper performance of their duties. In order to meet this determination, the second article of the decree No. 210 ordered the secretaries of Health establish regional planning to form a hierarchical Network State and / or Regional Networks of High-complexity Cardiovascular Care. The single paragraph defined the Networks of High-complexity Cardiovascular Care shall be composed of high-complexity cardiovascular care units and referral centers for high cardiovascular complexity. In turn, the high cardiovascular complexity care and referral centers in high cardiovascular complexity conditions shall provide technical, physical facilities, equipment and human resources to provide specialized assistance, develop strong coordination and integration with the local system and regional health care and meet the criteria of the National Humanization Policy. The skills and responsibilities of the departments located in assistance units and referral centers for high cardiovascular complexity care shall be regulated by the Department of Health Care by a specific rule. The minimum parameters of operation of these units were defined in Annex I of Ordinance No. 210. The same decree No. 210, in the first article of the second paragraph, defined as the Reference Center for Highcomplexity Cardiovascular Care a High-complexity Cardiovascular Care Unit exercising the auxiliary role of a technical nature, the manager in the policies of care in cardiovascular diseases, must possess attributes such as: be a teaching hospital, certified by the Ministry of Education and MS. According to the Interministerial ordinance No. 1000 of the Ministry of Education, April 2004, to be a teaching hospital, this should have a territorial base of operations defined, with a maximum of a referral center for every four million inhabitants; participate articulated and integrated with the system local and regional have structure of organized research and teaching, and programs with established protocols, have adequate management structure capable of ensuring the efficiency, efficacy and effectiveness of actions provided; support the activities of managers in regulation, monitoring, control and evaluation, including quality studies and studies of cost-effectiveness; participate as polo professional development in partnership with the manager, based on the Politics of Permanent Education for SUS, MS, and offers at least four services defined in the fifth article of this ordinance. Importantly, the requirement for territorial basis of performance (maximum a referral center for every four million inhabitants) was revoked in May 2006 by the third article of the decree No. 384. Already the second article, the first paragraph of this Ordinance provided that, in states with population less than 4,000,000 inhabitants, there should be no more than a reference center, since the unit would meet the requirements. The second paragraph of the same article that preferably should be defined as referral centers enabled public hospitals, private philanthropic and private financial gain, in that order, that would fit in the first article, second paragraph, item I. Interviewed cardiovascular surgeons of BSCVS considered the technical criteria contained in the annex to the decree No. 210 as not mutually exclusive and that could serve as a bargaining tool for improvement of some institutions. Others considered as a limiting factor in enrollment, especially in the aspects concerning the formation of multidisciplinary teams, the physical structure and the acquisition of costly equipment. It is understood that the criteria as parameters are needed to provide adequate service to the segment of cardiac patients. However, based on the fact that the target set in the policy was 239 centers and only 66 were actually enabled, this indicates that the policy was limiting access to the institutions. 5. Update the accreditation system and adapt it to provide procedures for High Complexity, High Technology and High Cost. Article 11 of Decree No 210 incorporated six annexes: Classification Standards and Accreditation of Highcomplexity Cardiovascular Care Units, Survey Manager Form, MS Survey Form, List of Procedures Included in Tables SIA and SIH / SUS for Cardiovascular Care, Distribution Parameters for Population Assistance Services and Reference Centers for High Cardiovascular Complexity, List of Procedures Excluded from SIA and SIH / SUS Tables. It was created, also, the Table of Compatibility between procedure performed and orthotics, prosthetics and special materials (OPM) and the Cardiovascular Care Procedure Organization. In the questionnaire applied to cardiovascular surgeons of BSCVS 88.3% of the respondents opined by the need to implement a National Database. They considered that to achieve this it would be necessary to match diagnosis tables, procedures and OPM, using an internationally accepted nomenclature, since the specialty is of high complexity and thus it is essential to be included in the international context. 6. Improving the system of information concerning the Cardiovascular Care. The sixth article established a deadline of 120 days to deploy management tools, such as the "Brazilian Registry of Cardiovascular Surgery," but until the completion of this survey, in December 2011, it had not occurred. The arguments mentioned in the interviews of directors of companies as well as the managers of MS, in explanation for the non-implementation of the record were: lack of political will, the inability to formulate DATASUS the database and lack of interest by having doubts SBCCV about how the data will be used. In this regard were clearly identified divergent interests, mainly related to power management to the database can generate. Most cardiovascular surgeons surveyed (91.4%) believes that the database should be managed by the department (DCCVPed) or by BSCVS, while 76.6% believe that the filling should be mandatory and linked to the authorization for hospital admission (AHA) and 93.1% participate in the record even if not compulsory to fill. Establish mechanisms for the regulation, supervision, control and evaluation of the care provided to these patients. These mechanisms were effective, in part, by registering cardiovascular surgery. That record, in turn, should equip the actions specified in Annex I of Ordinance No. 210, topic 1.7. Under Annex, maintenance of accreditation services would be conditional: the continued fulfillment of the standards established in the ordinance for unity; evaluation to be performed by periodic audits or recommended by the Department of Health Care (SAS), run by the Department of Health under whose management is unity, and the reports generated should then be forwarded to the General Coordination for High Complexity Department of Specialized Care (DAE / MS) for analysis that would determine the continuation or suspension of accreditation, based on compliance or not the standards established by ordinance, regular reports on the evaluation and annual production. According to the surgeons interviewed, the record could be powered by untrusted data, since they would have among their purposes to support maintenance or suspension of accreditation. Unfortunately, it remains a challenge to be faced in the fight for effective implementation of policies, in which universal access to effective and resolution should be a guarantee. Overcoming the gap between rule and practice is the way to go for multithreaded interested in solving the ills of this population as specific, as is the scope of notorious intentions contained in ordinances. The universality, comprehensiveness and equity of health care shall be the goal of health policies that propose to be inducing quality healthcare. REFERENCES

Alternate abstract:

ARTIGO ESPECIAL Análise das portarias que regulamentam a Política Nacional de Atenção Cardiovascular de Alta Complexidade Valdester Cavalcante Pinto JúniorI; Maria Nazaré de Oliveira FragaII; Sílvia Maria de FreitasIII IEspecialista em Cirurgia Cardiovascular; Mestre em Avaliação em Políticas Públicas-UFC; Chefe de Cirurgia Cardiovascular Pediátrica do Hospital Dr. Carlos Alberto Studart Gomes/SESA, do Incor Criança, Fortaleza, CE, Brasil IIDoutora em Enfermagem, Professora do Curso de Mestrado em Avaliação de Políticas Públicas - Universidade Federal do Ceará, Fortaleza, CE, Brasil IIIProfessora do Curso de Mestrado em Avaliação de Políticas Públicas -Universidade Federal do Ceará, Fortaleza, CE, Brasil Endereço para correspondência Endereço para correspondência Valdester Cavalcante Pinto Júnior Avenida Litorânea, 2040 - Lt A3/12 Fortaleza, CE Brasil - CEP 60835-175 E-mail: [email protected] Descritores: Coração/cirurgia. Procedimentos cirúrgicos cardíacos. Cuidado da criança. Política de saúde. Saúde pública. Portarias ministeriais são instrumentos utilizados para criar, adequar ou regulamentar políticas públicas estabelecidas a partir de demandas sociais. As portarias, objeto deste estudo, inauguram outro momento da assistência aos portadores de doenças cardiovasculares e o conjunto dá forma à Política Nacional de Atenção Cardiovascular de Alta Complexidade. O estudo que segue é um capítulo da dissertação de mestrado: Avaliação da Política Nacional de Atenção Cardiovascular de Alta Complexidade com foco na Cirurgia Cardiovascular Pediátrica, realizado na Universidade Federal do Ceará no Curso de Mestrado Profissional em Avaliação de Políticas Públicas. Procuramos fazer a análise das concepções em que as portarias se fundamentam, à luz dos princípios do Sistema Único de Saúde (SUS), da literatura que teoriza tais princípios, dos discursos de gestores e diretores de Sociedades envolvidas no mérito e dos resultados de questionário aplicado a cirurgiões cardiovasculares pertencentes à Sociedade Brasileira de Cirurgia Cardiovascular (SBCCV), sendo calculada a amostra tomando como referência 778 profissionais, número fornecido pela SBCCV, estando distribuídos, em abril de 2009, da seguinte forma: 30 (4%) na região Norte, 107 (14%) na região Nordeste, 68 (9%) na região Centro-Oeste, 437 (56%) na região Sudeste e 136 (17%) na Sul. A definição da amostra, para um erro de amostragem de e=4,87%, ficou em 266 cirurgiões. Com base nesse cálculo, a amostra conforme a região correspondeu a dez cirurgiões da região Norte, 58 da região Nordeste, 25 da região Centro-Oeste, 130 da Sudeste e 43 da Sul, num total de 266 cirurgiões cardiovasculares. Em janeiro de 2003, o Ministério da Saúde (MS) iniciou discussão a respeito de ampla reforma para o atendimento da alta complexidade e promoveu intensa discussão para formular a denominada: Política Nacional de Atenção Cardiovascular de Alta Complexidade. As mais diversas especialidades foram representadas por suas respectivas Sociedades, como a Sociedade Brasileira de Cardiologia, Sociedade Brasileira de Radiologia Intervencionista e Cirurgia Vascular, Sociedade Brasileira de Hemodinâmica e Cardiologia Intervencionista, Sociedade Brasileira de Angiologia e de Cirurgia Vascular, Sociedade Brasileira de Arritmias Cardíacas e a própria SBCCV, com seus Departamentos de Estimulação Cardíaca Artificial e Departamento de Cirurgia Cardiovascular Pediátrica (DCCVPed). Nesse cenário, puderam ser observadas disputas por locus de atuação médica, espaço de atuação para instituições hospitalares e incorporação de produtos [1]. O MS propunha centralizar na rede de hospitais universitários o atendimento de alto custo e diminuir o número de hospitais conveniados da rede privada, sinalizando para a elaboração de uma política excludente, tendo em vista as várias exigências para as instituições hospitalares no que tange a estrutura física, equipamentos e recursos humanos, sem a devida contrapartida financeira [1]. A SBCCV, durante esse processo, sinalizou para a elaboração de uma política que atendesse às diferenças regionais e para o fato de que era impossível atender a todas as exigências propostas pelo MS, já que a maioria dos serviços cadastrados em cirurgia cardiovascular estava passando por sérias dificuldades financeiras [1]. O marco legal veio em 15 de junho de 2004 por meio de dois dispositivos: a portaria nº 1169/GM [2], que instituiu a Política Nacional de Atenção Cardiovascular de Alta Complexidade, e a portaria nº 210 SAS/MS [3], que regulamentou a cirurgia cardiovascular pediátrica. Essa portaria foi alterada em alguns parâmetros em 26 de maio de 2006, com a publicação da portaria SAS/MS nº 384. A portaria nº 1169/GM/2004 instituiu a Política Nacional de Atenção Cardiovascular de Alta Complexidade, considerando alguns requisitos, enumerados abaixo, que deram suportes conceituais para a elaboração da portaria nº 210 e seus anexos, que serão discutidos a seguir. 1. Atendimento integral aos portadores de patologias cardiovasculares do Sistema Único de Saúde - SUS. Entende-se como atenção integral o suporte necessário ao cuidado daquele que necessita tratamento. Esse conceito é de grande importância, haja vista que a integralidade constitui um dos princípios do SUS. A integralidade é usada de forma corrente com referência à diretriz da atenção integral, como princípio de igualdade da assistência, vista como conjunto de ações e serviços de saúde, preventivos e curativos, individuais e coletivos, nos diversos níveis de complexidade do sistema [4]. 2. Necessidade de organizar a assistência aos referidos pacientes, em serviços hierarquizados e regionalizados, e com base nos princípios da universalidade e integralidade das ações de saúde. Universalidade se define como o acesso de todos a todos os serviços. Integralidade é a forma de atenção que compreende todos os níveis da atenção em saúde, ou seja, da promoção à assistência. Entretanto, a portaria de 2004 não definiu de que forma se daria a relação dos três níveis de atenção no que tange a cardiologia e cirurgia cardiovascular pediátrica. Para que os princípios de universalidade e de integralidade fossem operacionalizados, seria necessária a estruturação de modelo específico de atenção à gestante e ao neonato, bem como acompanhamento pediátrico, ou seja, a formação de equipe multiprofissional para o cuidado nos níveis de atenção primária e secundária, bem como dotar as instituições que prestassem esse tipo de atenção com equipamentos necessários ao diagnóstico e ao acompanhamento dos pacientes. Também não foi estabelecido o quanto e de quais fontes seriam oriundos os recursos para ressarcimento desses investimentos, além de determinar que todas as unidades de cirurgia cardiovascular participassem do programa, como descrito no parágrafo 1.4 do anexo I. Quanto à regionalização, o anexo IV da portaria nº 210 estabeleceu alguns parâmetros territoriais de atuação. No caso das Unidades de Assistência de Alta Complexidade em Cirurgia Cardiovascular Pediátrica, deveria haver a proporção de uma Unidade para atender 800.000 habitantes (1:800.000), definindo também que fossem adotados os critérios estabelecidos no artigo oitavo da mesma portaria. Na definição dos quantitativos e distribuição geográfica das Unidades, tais como: população a ser atendida; necessidade de cobertura assistencial; mecanismos de acesso com os fluxos de referência e contrarreferência; capacidade técnica e operacional dos serviços; série histórica de atendimentos realizados, levando em conta a demanda reprimida; integração com a rede de referência hospitalar em atendimento de urgência e emergência, com os serviços de atendimento pré-hospitalar, com a Central Nacional de Regulação de Alta Complexidade (CNRAC) e com os demais serviços assistenciais ambulatoriais e hospitalares disponíveis no Estado. No mesmo artigo foi definido que, em caso de ausência de instituição para realizar qualquer procedimento de alta complexidade cardiovascular, o gestor local deveria garantir sua realização encaminhando o paciente pela CNRAC. Dessa forma, estariam presentes mecanismos de alocação racional de recursos, organizados com base numa disposição tecnológica hierárquica, buscando ampliar a capacidade de atenção na porta de entrada do sistema, de forma que as demais tecnologias fossem incorporadas com suporte nas necessidades de cada usuário, considerando economias de escala e escopo. Porém, observa-se que ainda é necessária devida distribuição geográfica dos serviços de saúde, dos recursos humanos e dos programas, possibilitando a conexão de vários conhecimentos clínicos e de saúde coletiva para prover atenção integral com mecanismos e estratégias de articulação e referenciamento adequado, suficientes para responder às necessidades de saúde de determinada base populacional [5]. A estruturação de uma rede regionalizada de atenção à saúde possui como objetivos a provisão de atenção contínua, integral, de qualidade, responsável e humanizada à saúde, articulada segundo a complementaridade de variadas densidades tecnológicas e organizada por critérios de eficiência microeconômica na aplicação dos recursos. Esse tipo de rede deve ser constituído mediante o planejamento, a gestão e o financiamento intergovernamentais cooperativos e voltados para o desenvolvimento de soluções integradas da política de saúde adaptadas às necessidades populacionais de cada espaço regional singular [5]. Em complementação ao que foi definido pelo MS, Artmann & Rivera [6] entendem que a regionalização pressupõe a alocação de recursos de saúde em determinada área, em ordem que facilite o acesso, ofereça alta qualidade dos serviços, baixo custo e equidade com melhor e mais rápidas respostas aos desejos e necessidades dos consumidores. O enfoque de regionalização propõe-se encontrar equilíbrio entre a excessiva centralização estrutural e a descentralização total dos serviços de saúde. A distância é um dos elementos mais importantes para estabelecer a distribuição geográfica das instituições de saúde dentro do sistema regionalizado. Não se pode deixar de comentar que em um País com distâncias gigantescas, diferenças regionais enormes, destacando-se os extremos entre regiões quase despovoadas e centros urbanos com superpopulação, é preciso pensar com criatividade e contextualizar os parâmetros mediante adaptações viáveis e que tragam impactos positivos sobre a situação problemática. O grande critério para o caso é o acesso ao tratamento [6]. No caso da saúde, a regionalização obedece prioritariamente ao critério de planejamento de oferta de serviços e à necessidade de racionalizar a dinâmica de articulação desses, instituindo maior coordenação para atingir resultados em termos de acesso e equidade adequados [6]. A regionalização do cuidado em cardiologia pediátrica ou a colaboração entre centros regionais pode não apenas melhorar os resultados por concentrar a experiência de equipes qualificadas em determinadas instituições, como também facilitar a avaliação da qualidade em razão do aumento do número de pacientes operados [7]. Relacionada a essa proposta, os cirurgiões cardiovasculares entrevistados indicaram a criação de centros de atenção para atendimento das cardiopatias de maior complexidade. Tais centros deveriam ser distribuídos nas várias regiões, responsáveis pela base territorial previamente estabelecida, propiciando acesso rápido e atenção qualificada, já que em algumas doenças a demora na assistência pode ser o diferencial no resultado do tratamento e em outras na sobrevida a longo prazo do paciente. A portaria em apreço adotou o princípio da universalidade, que é o acesso, de forma indiscriminada, de todos a todos os serviços, com base na regionalização e hierarquização da atenção. Contudo, falta na política atual a abordagem que vise atender às iniquidades na atenção cardiovascular, notadamente em algumas regiões. Falar em universalidade não é a mesma coisa que promover equidade. Segundo Garrafa & Porto [8], "igualdade é consequência da equidade. O reconhecimento das diferenças e a supressão das necessidades possibilitam alcançar a igualdade". A equidade tem sido interpretada, seja no discurso oficial, seja na fala dos agentes sociais de relevância na arena sanitária, como um princípio do SUS. É justo que seja assim, pois os sistemas universais devem buscar a equidade [9]. Para Neves [10], a equidade representa igual acessibilidade aos cuidados de saúde, mediante sua redistribuição diferenciada: atribuindo mais a quem tem menos e o mesmo a quem tem as mesmas condições, numa ação reguladora das desigualdades. Isto só é possível pelo princípio da solidariedade, em que todos os homens redistribuam os bens entre si. Sugere a aplicação de dois critérios em especial: o da necessidade médica, como fator de racionalização e o da igualdade de oportunidades, como fator de acessibilidade universal. A Norma Operacional Básica (NOB) 96 teve como objetivo promover equidade com qualidade e racionalidade nos gastos. Para que se evitasse processo acumulativo injusto por parte de alguns municípios, com a crescente espoliação de outros, a composição dos sistemas municipais e a ratificação das programações pactuadas nos respectivos conselhos de saúde visaram aos estabelecimentos de redes regionais para ampliação do acesso com qualidade e menor custo [11]. O anexo II da portaria nº 210 tomou por base o princípio da integralidade proposto na portaria nº 1169/GM, tratando das normas de classificação e credenciamento de unidades de assistência em alta complexidade cardiovascular. Ficou então definido que tais unidades deveriam oferecer assistência especializada e integral aos pacientes com doenças do sistema cardiovascular e, para tanto, era necessário: aderir aos critérios da Política Nacional de Humanização; desenvolver ou participar de programas de prevenção e detecção precoce das doenças do sistema cardiovascular; oferecer diagnóstico e tratamento destinado ao atendimento de pacientes portadores de doença do sistema cardiovascular; desenvolver programa de reabilitação, suporte e acompanhamento por meio de procedimentos específicos que promovessem a melhoria das condições físicas e psicológicas do paciente, além de atuar no preparo pré-operatório ou como complemento pós-operatório no sentido da restituição da capacidade funcional. Em linhas gerais, a política atendeu ao princípio da integralidade quando englobou na assistência: diagnóstico precoce, tratamento, prevenção e reabilitação. Pauli [12] divide os níveis de prevenção em primária, a qual é subdividida em promoção de saúde e proteção específica; secundária, em diagnóstico com tratamento precoce e limitação da invalidez; e terciária com a reabilitação. Em nenhuma das portarias citadas e que compõem a política Nacional existe qualquer referência ao tipo de ação ou para qual tipo de doença a prevenção primária deva ser desenvolvida. As determinações limitam-se a estipular que tais atividades devam ser desenvolvidas de maneira articulada com os programas e normas definidas pelo vários níveis de gestão. Quando se trata de diagnóstico precoce, a política não estabelece normas para adequação dos serviços à atenção do segmento, que começa no cuidado ao feto, passa pelo neonato e vai até a criança. Por outro lado, seriam necessários estrutura física, equipamentos e profissionais especializados para que tais fossem cumpridas. As fontes de recursos para efetivação das diversas ações também representam lacuna importante na política. Não é demais ressaltar que diagnóstico precoce aponta para o tratamento em tempo programado e que o artigo segundo da portaria nº 1169/GM determinou que as secretarias de Estado da Saúde estabelecessem planejamento regional e hierarquizado para formar a Rede Estadual e/ou Regional de Atenção em Alta Complexidade Cardiovascular, com a finalidade de prestar assistência aos portadores de doenças do sistema cardiovascular que necessitassem ser submetidos aos procedimentos classificados como de alta complexidade. Quanto à reabilitação, prevenção terciária e outras ações de promoção da integralidade, as portarias não explicitam a fonte pagadora, tornando-se inviável sua efetivação por parte dos prestadores, ainda que esses tenham sido firmado no ato do credenciamento. 3. Garantir a esses pacientes a assistência nos vários níveis de complexidade, por intermédio de equipes multiprofissionais, utilizando-se de técnicas e métodos terapêuticos específicos. Esse tópico remete à integralidade, sendo que sua efetivação esbarra na falta de articulação entre as ações nos diversos níveis, na falta de infraestrutura dos serviços que prestam a atenção primária e secundária e na deficiente capacidade da atenção terciária para atender à demanda nesse nível. Torna-se necessário salientar que o princípio da interssetorialidade deveria estar referido, remetendo às condições alimentares, de educação e de lazer, pilares para garantir uma boa saúde cardiovascular. 4. Necessidade de uma nova conformação das Redes Estaduais e/ou Regionais de Atenção em Alta Complexidade Cardiovascular, bem como de determinar o seu papel na atenção à saúde e as qualidades técnicas necessárias ao bom desempenho de suas funções. Para atender a essa determinação, o artigo segundo da portaria nº 210 determinou que as secretarias de Estado da Saúde estabelecessem planejamento regional hierarquizado para formar a Rede Estadual e/ou Regional de Atenção em Alta Complexidade Cardiovascular. O parágrafo único definiu que a Rede de Atenção em Alta Complexidade Cardiovascular deveria estar composta de unidades de assistência em alta complexidade cardiovascular e centros de referência em alta complexidade cardiovascular. Por sua vez, as unidades de assistência em alta complexidade cardiovascular e os centros de referência em alta complexidade cardiovascular deveriam oferecer condições técnicas, instalações físicas, equipamentos e recursos humanos adequados à prestação de assistência especializada, desenvolver forte articulação e integração com o sistema local e regional de atenção à saúde e atender aos critérios da Política Nacional de Humanização. As aptidões e atribuições dos serviços situados em unidades de assistência e nos centros de referência em alta complexidade cardiovascular devem ser regulamentadas pela Secretaria de Atenção à Saúde em portaria específica. Os parâmetros mínimos de funcionamento dessas unidades foram definidos no anexo I da portaria nº 210. A mesma portaria nº 210, no primeiro artigo do segundo parágrafo, definiu como Centro de Referência em Alta Complexidade Cardiovascular uma Unidade de Assistência de Alta Complexidade Cardiovascular que exerça o papel auxiliar, de caráter técnico, ao gestor nas políticas de atenção nas doenças cardiovasculares, devendo possuir como atributos: ser hospital de ensino, certificado pelo MS e Ministério da Educação. De acordo com a portaria Interministerial nº 1000 do Ministério da Educação, de abril de 2004, para ser hospital de ensino, este deveria ter base territorial de atuação definida, com máximo de um centro de referência para cada quatro milhões de habitantes; participar de forma articulada e integrada com o sistema local e regional; ter estrutura de pesquisa e ensino organizada, com programas e protocolos estabelecidos; ter adequada estrutura gerencial, capaz de zelar pela eficiência, eficácia e efetividade das ações prestadas; subsidiar as ações dos gestores na regulação, fiscalização, controle e avaliação, incluindo estudos de qualidade e estudos de custo-efetividade; participar como polo de desenvolvimento profissional em parceria com o gestor, tendo como base a Política de Educação Permanente para o SUS, do MS; além de oferecer no mínimo quatro dos serviços definidos no artigo quinto dessa portaria. É importante salientar que a obrigatoriedade de base territorial de atuação (máximo de um centro de referência para cada quatro milhões de habitantes) foi revogada em maio de 2006 pelo artigo terceiro da portaria nº 384. Já o artigo segundo, no parágrafo primeiro dessa a portaria, estabeleceu que, nos estados com população menor do que 4.000.000 de habitantes, deveria haver no máximo um Centro de Referência, desde que a unidade atendesse às exigências previstas. O parágrafo segundo do mesmo artigo definiu que preferencialmente deveriam ser habilitados como centros de referência os hospitais públicos, privados filantrópicos e privados lucrativos, nessa ordem, que se enquadrassem no artigo primeiro, parágrafo segundo, inciso I. Os cirurgiões cardiovasculares da SBCCV entrevistados consideraram os critérios técnicos contidos no anexo da portaria nº 210 como não excludentes e que poderiam servir como instrumento de negociação para melhorias de algumas instituições. Outros consideraram como fator limitante no cadastramento, principalmente nos aspectos quanto à formação de equipes multiprofissionais, na estruturação física e na aquisição de equipamentos de alto custo. Entende-se que os critérios estabelecidos são necessários como parâmetros para oferecer atendimento adequado ao segmento de pacientes cardiopatas. No entanto, tendo como base o fato de que a meta estabelecida na política foi de 239 centros e que apenas 66 foram efetivamente habilitados, isso indica que a política foi limitante no acesso para as instituições. 5. Atualizar o sistema de credenciamento e adequá-lo à prestação dos procedimentos de Alta Complexidade, Alta Tecnologia e Alto Custo. O artigo 11 da portaria nº 210 incorporou seis anexos: Normas de Classificação e Credenciamento de Unidades de Assistência em Alta Complexidade Cardiovascular, Formulário de Vistoria do Gestor, Formulário de Vistoria do MS, Relação dos Procedimentos Incluídos nas Tabelas SIA e SIH/SUS para a Assistência Cardiovascular, Parâmetros de Distribuição Demográfica para os Serviços de Assistência e os Centros de Referência em Alta Complexidade Cardiovascular, Relação dos Procedimentos Excluídos das Tabelas SIA e SIH/SUS. Foi criada, também, a Tabela de Compatibilidade entre procedimento realizado e órteses, próteses e materiais especiais (OPM) e a Organização dos Procedimentos da Assistência Cardiovascular. No questionário aplicado aos cirurgiões cardiovasculares da SBCCV, 88,3% dos respondentes opinaram pela necessidade de implantação de um Banco de Dados Nacional. Consideraram que, para essa concretização haveria a necessidade de adequar as tabelas de diagnóstico, dos procedimentos e de OPM, utilizandose nomenclatura internacionalmente aceita, já que a especialidade é de altíssima complexidade e, dessa forma, é essencial estar inclusa no contexto internacional. 6. Aperfeiçoamento do sistema de informação, referente à Assistência Cardiovascular. O artigo sexto estabeleceu o prazo de 120 dias para implantar instrumentos da gestão, como o "Registro Brasileiro de Cirurgia Cardiovascular", porém até a conclusão dessa pesquisa, em dezembro de 2011, isso ainda não havia ocorrido. Os argumentos referidos nas entrevistas de diretores de sociedades, bem como dos gestores do MS, em explicação para a não implementação do registro foram: falta de decisão política, incapacidade do DATASUS para formular o banco de dados e falta de interesse da SBCCV por ter dúvidas sobre como serão utilizados os dados. Em relação a isso foram identificados claramente interesses divergentes, relacionados, principalmente, ao poder que a administração do banco de dados pode gerar. A maioria dos cirurgiões cardiovasculares entrevistados (91,4%) acredita que o Banco de Dados deve ser gerenciado pelo departamento (DCCVPed) ou pela própria SBCCV, sendo que 76,6% entendem que o preenchimento deveria ser obrigatório e vinculado à cobrança da Autorização de internação hospitalar (AIH) e 93,1% participariam do registro mesmo que não fosse de preenchimento compulsório. 7. Estabelecer mecanismos de regulação, fiscalização, controle e avaliação da assistência prestada a esses pacientes. Os mecanismos referidos se concretizariam, em parte, por meio do registro de cirurgia cardiovascular. Esse registro, por sua vez, deveria instrumentalizar as ações previstas no anexo I da portaria nº 210, tópico 1.7. Nos termos do anexo, a manutenção do credenciamento dos serviços estaria condicionada: ao cumprimento continuado das normas estabelecidas na portaria pela unidade; à avaliação a ser realizada por auditorias periódicas ou recomendadas pela Secretaria de Atenção à Saúde (SAS), executadas pela Secretaria de Saúde sob cuja gestão esteja a unidade, sendo que os relatórios daí gerados deveriam ser encaminhados à Coordenação Geral de Alta Complexidade do Departamento de Atenção Especializada (DAE/MS) para análise; este determinaria a manutenção ou suspensão do credenciamento, tomando por base o cumprimento ou não das normas estabelecidas na portaria, nos relatórios periódicos de avaliação e na produção anual. De acordo com os cirurgiões entrevistados, o registro poderia ser alimentado por dados não fidedignos, já que eles teriam entre suas finalidades fundamentar a manutenção ou suspensão de credenciamentos. Infelizmente, permanece um grande desafio a ser enfrentado na luta pela implementação efetiva de políticas, em que o acesso universal com efetividade e resolubilidade deveriam ser uma garantia. Transpor o abismo entre a norma e a prática é o caminho a ser percorrido pelos vários segmentos interessados na solução das mazelas dessa população tão específica, visto que é notória a abrangência das intenções contidas nas portarias. A universalidade, a integralidade e a equidade da atenção à saúde devem ser o objetivo das políticas de saúde que se propõem ser indutoras de saúde com qualidade. Artigo recebido em 7 de abril de 2012 Artigo aprovado em 26 de setembro de 2012 Trabalho realizado na Universidade Federal do Ceará, Fortaleza, CE, Brasil.

Ministerial decrees are tools used to create, adapt or regulatory policies established from social demands. The ordinances, subject of this study, inaugurate another moment of care to patients with cardiovascular disease and all forms to the. National Policy of High-complexity Cardiovascular Care

The study that follows is a chapter of dissertation: Evaluation of the National Policy of High-complexity Cardiovascular Care focusing on Pediatric Cardiovascular Surgery, held at the Federal University of Ceará in the Professional Master's Degree Course in Public Policy Evaluation.

We try to analyze the concepts on which the ordinance is based, according to the principles of the Unified Health System (SUS), literature theorizes that such principles, discourses of managers and directors of companies involved in the merits and results of questionnaire applied to cardiovascular surgeons belonging to the Brazilian Society of Cardiovascular Surgery (SBCCV), the sample is calculated by reference to 778 professionals, number provided by SBCCV being distributed in April 2009, as follows: 30 (4%) in the North, 107 (14%) in the Northeast, 68 (9%) in the Midwest region, 437 (56%) and 136 in the Southeast (17%) in the South The sample size for a sampling error of e = 4.87%, was 266 surgeons. Based on this calculation, the sample by region corresponded to ten surgeons in the North, 58 in the Northeast, 25 in the Midwest, Southeast and 43 130 of the South, a total of 266 cardiovascular surgeons.

In January 2003, the Ministry of Health (MS) initiated discussion about comprehensive reform to meet the high complexity and promoted intensive discussion to formulate the so-called: National Policy of High-complexity Cardiovascular Care.

The various specialties were represented by their respective companies, as the Brazilian Society of Cardiology, Brazilian Society of Interventional Radiology and Vascular Surgery, Brazilian Society of Interventional Cardiology, Brazilian Society of Angiology and Vascular Surgery, Brazilian Society of Cardiac Arrhythmias and BSCVS, with its Departments of Cardiac Pacing and Department of Pediatric Cardiovascular Surgery (DCCVPed).

In this scenario, disputes could be observed by medical locus of activity, performance space for hospitals and incorporation of products [1]. The MS proposed to centralize network of university hospitals in the care of high cost and decrease the number of hospitals to the private network, signaling for the development of an exclusionary policy, keeping in view the various requirements for hospitals regarding the physical structure, equipment and human resources, without adequate financial compensation [1].

The SBCCV, during this process, signaled the development of a policy that would meet the regional differences and the fact that it was impossible to meet all the requirements proposed by MS, since most services registered in cardiovascular surgery was experiencing serious financial difficulties [1].

The legal framework came on June 15, 2004 through two devices: the decree No. 1169/GM [2], which established the National Policy of High-complexity Cardiovascular Care, and Ordinance No. 210 SAS / MS [3] regulated the pediatric cardiovascular surgery. This ordinance was amended in some parameters on May 26, 2006, with the publication of the ordinance SAS / MS No 384.

The decree No. 1169/GM/2004 instituted the National Policy of High-complexity Cardiovascular Care considering some requirements, listed below, who gave props to the conceptual elaboration of Ordinance No. 210 and its annexes, which are discussed below.

1. Comprehensive care to patients with cardiovascular pathologies of the Unified Health System - SUS. Integral care consists of the necessary support to those that need treatment. This concept is of great importance, given that comprehensiveness is one of the principles of the SUS.

Integrality is used on an ongoing basis with reference to the guideline of integrated care as the principle of equality of care, seen as a set of actions and, preventive and curative, individual and collective health services at different levels of system complexity [4].

2. Need to organize assistance to those patients on hierarchical and regional services, and based on the principles of universality and integrality of health. Universality is defined as access by all to all services. Integrality is the care that comprises all levels of health care, i.e., the provision of assistance.

However, the ordinance of 2004 did not define how the relationship would take the three levels of care with respect to cardiology and pediatric cardiovascular surgery. In order to the principles of universality and integrality to be effective, it would be necessary to structure the specific model of care for pregnant women and the newborn as well as pediatric monitoring, i.e., the creation of a multidisciplinary care team for the primary and secondary care levels as well as capacitating institutions that provide this kind of assistance with necessary equipment for the diagnosis and monitoring of patients. It was also not established how much and from what sources would be the resources to redress these investments, in addition to determining that all units shall participate in the cardiovascular surgery program, as described in paragraph 1.4 of Annex I.

As for regionalization, Annex IV of Ordinance # 210 established some parameters of territorial operation. In the case of High Complexity Care Units in Pediatric Cardiovascular Surgery, there shall be a ratio of one unit to serve 800,000 inhabitants (1:800.000), which were also adopted by defining the criteria of article eight of the same ordinance.

In defining the quantitative and geographic distribution of units, such as: population to be served; need for health care coverage, access mechanisms with reference and counter reference, technical and operational services; series of visits, taking into account the pent-up demand; integration with the hospital reference network of emergency care and emergency services with prehospital care, with the High Complexity National Regulatory Central (CNRAC) and other outpatient and hospital care services available in the State. In the same article it was decided that, in the absence of any institution to perform highly complex cardiovascular procedures, the local manager should ensure their achievement by directing the patient through CNRAC.

Thus, these mechanisms would be rational allocation of resources, organized on the basis of technological hierarchy disposition, seeking to expand the capacity of assistance at the entrance of the system, so that other technologies were incorporated to support the needs of each user considering economies of scale and scope. However, it is observed that it is still needed due geographical distribution of health services, human resources and programs, enabling the connection of multiple clinical knowledge and collective health to provide comprehensive care with strategies and mechanisms of articulation and appropriate referencing, sufficient to meet the health needs of specific population base [5].

The structuring of a network of regionalized health care has as its objectives the provision of continuous, integral, quality, responsible and humane health care, articulated according to the complementarity of various densities and technology organized by criteria of microeconomic efficiency in use of resources. This kind of network should be made by the planning, management and financing intergovernmental cooperative and focused on the development of integrated health policy tailored to the population needs of each singular regional space [5]. In complement to what has been defined by MS, Artmann & Rivera [6] i it understood that regionalization requires the allocation of health resources in a given area, in order to facilitate access, offer high quality services, low cost and with better fairness and faster responses to the desires and needs of consumers. The regionalization approach is proposed to find the balance between excessive centralization and complete decentralization of structural health services.

The distance is one of the most important elements to establish the geographical distribution of health institutions within the regionalized system. One cannot help commenting that in a country with vast distances, huge regional differences, especially between the extremes almost depopulated regions and urban centers with overpopulation, we need to think creatively and contextualize parameters through adaptations that bring viable and positive impacts on the problematic situation. The major criterion for the case is access to treatment [6].

In the case of health care, regionalization meets the criterion of priority planning service provision and the need to rationalize the relationship of these dynamics, establishing greater coordination to achieve results in terms of access and equity adequate [6].

Regionalization of care in pediatric cardiology or collaboration among regional centers can not only improve results by focusing the expertise of qualified staff in some institutions, but also to help evaluate the quality due to the increased number of patients [7].

Related to this proposal, interviewed cardiovascular surgeons indicated the establishment of care centers for care of heart disease of higher complexity. Such centers should be distributed in various regions responsible for territorial base previously established, providing quick and skilled care, as in some diseases the delay in care can be the difference in treatment outcome and other long-term survival in patients .

The ordinance in question has adopted the principle of universality, which is access, indiscriminately, of all to all services, based on regional and hierarchical attention. However, the current policy lacks an approach that aims to meet the inequities in cardiovascular care, especially in some regions. Speaking universality it is not the same thing as promoting equity. According to Bottle & Porto [8], "equality is a consequence of the equity. The recognition of differences and suppression of needs make possible the achievement of equality."

Equity has been interpreted both in official discourse and in the speech of relevance social agents in the arena of health, as a principle of SUS. It is fair that this is so because the universal systems shall seek fairness [9]. According to Neves [10], equity is equal access to health care through its differentiated redistribution: giving more to those who have less and who even have the same conditions, in a regulatory action of inequalities. This is possible only by the principle of solidarity, in which all men redistribute goods among themselves. It suggests the application of two criteria in particular: the medical need, as a factor of rationalization and equal opportunities, as a factor of universal accessibility.

The Standard Operating Procedure (SOP) 96 aimed to promote equity with quality and rationality in spending. In order to avoid cumulative process unfairly by some municipalities, with the increasing dispossession of others, the composition of municipal systems and ratification of agreed schedules in their health councils aimed to establishments of regional networks for increased access to quality and lower cost [11].

Annex II of Ordinance No. 210 was based on the principle of integral proposed in Ordinance No. 1169/GM, dealing with classification standards and accreditation of units in highly complex cardiovascular care. It was then determined that such units shall offer comprehensive and specialized assistance to patients with diseases of the cardiovascular system and, therefore, it was necessary to: adhere to the criteria of the National Humanization Policy; develop or participate in prevention programs and early disease detection system cardiovascular; offer diagnosis and treatment for the care of patients with disease of the cardiovascular system; develop rehabilitation programs, support and monitoring through specific procedures that promote the improvement of physical and psychological conditions of the patient, besides acting in the preoperative preparation operative or postoperative in addition towards the restoration of functional capacity.

In general, the policy met the principle of completeness when encompassed in care: early diagnosis, treatment, prevention and rehabilitation.

Pauli [12] divides the levels of primary prevention, which is subdivided into health promotion and specific protection; minor in diagnosis with early treatment and limitation of disability, and tertiary prevention to rehabilitation. In none of these directives that comprise the National policy there is reference to the type of action or what kind of disease the primary prevention shall be developed. The determinations merely stipulate that such activities shall be developed in coordination with programs and standards defined by various levels of management.

When it comes to early diagnosis, the policy does not establish standards for adequacy of services to the attention of the segment, which begins in the care of the fetus, neonate and child. On the other hand, it would require physical structure, equipment and specialized professionals in order to such to be met.

The sources of funds for the execution of several actions also represent important gap in politics. It is worth mentioning that early diagnosis points to the scheduled time and treatment in the second article of the decree No. 1169/GM determined that the Secretaries of State for Health establish regional planning and hierarchical network to form the State and / or Regional High-complexity Cardiovascular Care, in order to assist patients with diseases of the cardiovascular system that needed to be subjected to procedures classified as high complexity.

As for rehabilitation, tertiary prevention and other actions to promote integrity, the ordinances do not specify the source of payment, making it infeasible adoption by providers, although these have been signed at the time of accreditation.

3. Ensuring these patients to assistance at various levels of complexity, through multidisciplinary teams, using techniques and specific therapeutic methods. This topic refers to the completeness, and its effectiveness hindered by a lack of coordination between actions at different levels, the lack of infrastructure of services provided to primary and secondary care and tertiary care deficient capacity to meet demand at that level. It is necessary to emphasize that the principle of intersectoriality shall be noted, referring to food conditions, education and leisure, pillars to ensure good cardiovascular health.

4. Need for a new conformation of State Networks and/ or Regional Networks of High-complexity Cardiovascular Care, as well as to determine their role in health care and the technical qualities necessary for the proper performance of their duties.

In order to meet this determination, the second article of the decree No. 210 ordered the secretaries of Health establish regional planning to form a hierarchical Network State and / or Regional Networks of High-complexity Cardiovascular Care. The single paragraph defined the Networks of High-complexity Cardiovascular Care shall be composed of high-complexity cardiovascular care units and referral centers for high cardiovascular complexity. In turn, the high cardiovascular complexity care and referral centers in high cardiovascular complexity conditions shall provide technical, physical facilities, equipment and human resources to provide specialized assistance, develop strong coordination and integration with the local system and regional health care and meet the criteria of the National Humanization Policy. The skills and responsibilities of the departments located in assistance units and referral centers for high cardiovascular complexity care shall be regulated by the Department of Health Care by a specific rule. The minimum parameters of operation of these units were defined in Annex I of Ordinance No. 210.

The same decree No. 210, in the first article of the second paragraph, defined as the Reference Center for Highcomplexity Cardiovascular Care a High-complexity Cardiovascular Care Unit exercising the auxiliary role of a technical nature, the manager in the policies of care in cardiovascular diseases, must possess attributes such as: be a teaching hospital, certified by the Ministry of Education and MS.

According to the Interministerial ordinance No. 1000 of the Ministry of Education, April 2004, to be a teaching hospital, this should have a territorial base of operations defined, with a maximum of a referral center for every four million inhabitants; participate articulated and integrated with the system local and regional have structure of organized research and teaching, and programs with established protocols, have adequate management structure capable of ensuring the efficiency, efficacy and effectiveness of actions provided; support the activities of managers in regulation, monitoring, control and evaluation, including quality studies and studies of cost-effectiveness; participate as polo professional development in partnership with the manager, based on the Politics of Permanent Education for SUS, MS, and offers at least four services defined in the fifth article of this ordinance.

Importantly, the requirement for territorial basis of performance (maximum a referral center for every four million inhabitants) was revoked in May 2006 by the third article of the decree No. 384. Already the second article, the first paragraph of this Ordinance provided that, in states with population less than 4,000,000 inhabitants, there should be no more than a reference center, since the unit would meet the requirements. The second paragraph of the same article that preferably should be defined as referral centers enabled public hospitals, private philanthropic and private financial gain, in that order, that would fit in the first article, second paragraph, item I.

Interviewed cardiovascular surgeons of BSCVS considered the technical criteria contained in the annex to the decree No. 210 as not mutually exclusive and that could serve as a bargaining tool for improvement of some institutions. Others considered as a limiting factor in enrollment, especially in the aspects concerning the formation of multidisciplinary teams, the physical structure and the acquisition of costly equipment.

It is understood that the criteria as parameters are needed to provide adequate service to the segment of cardiac patients. However, based on the fact that the target set in the policy was 239 centers and only 66 were actually enabled, this indicates that the policy was limiting access to the institutions.

5. Update the accreditation system and adapt it to provide procedures for High Complexity, High Technology and High Cost.

Article 11 of Decree No 210 incorporated six annexes: Classification Standards and Accreditation of Highcomplexity Cardiovascular Care Units, Survey Manager Form, MS Survey Form, List of Procedures Included in Tables SIA and SIH / SUS for Cardiovascular Care, Distribution Parameters for Population Assistance Services and Reference Centers for High Cardiovascular Complexity, List of Procedures Excluded from SIA and SIH / SUS Tables. It was created, also, the Table of Compatibility between procedure performed and orthotics, prosthetics and special materials (OPM) and the Cardiovascular Care Procedure Organization.

In the questionnaire applied to cardiovascular surgeons of BSCVS 88.3% of the respondents opined by the need to implement a National Database. They considered that to achieve this it would be necessary to match diagnosis tables, procedures and OPM, using an internationally accepted nomenclature, since the specialty is of high complexity and thus it is essential to be included in the international context.

6. Improving the system of information concerning the Cardiovascular Care.

The sixth article established a deadline of 120 days to deploy management tools, such as the "Brazilian Registry of Cardiovascular Surgery," but until the completion of this survey, in December 2011, it had not occurred.

The arguments mentioned in the interviews of directors of companies as well as the managers of MS, in explanation for the non-implementation of the record were: lack of political will, the inability to formulate DATASUS the database and lack of interest by having doubts SBCCV about how the data will be used. In this regard were clearly identified divergent interests, mainly related to power management to the database can generate. Most cardiovascular surgeons surveyed (91.4%) believes that the database should be managed by the department (DCCVPed) or by BSCVS, while 76.6% believe that the filling should be mandatory and linked to the authorization for hospital admission (AHA) and 93.1% participate in the record even if not compulsory to fill.

Establish mechanisms for the regulation, supervision, control and evaluation of the care provided to these patients.

These mechanisms were effective, in part, by registering cardiovascular surgery. That record, in turn, should equip the actions specified in Annex I of Ordinance No. 210, topic 1.7. Under Annex, maintenance of accreditation services would be conditional: the continued fulfillment of the standards established in the ordinance for unity; evaluation to be performed by periodic audits or recommended by the Department of Health Care (SAS), run by the Department of Health under whose management is unity, and the reports generated should then be forwarded to the General Coordination for High Complexity Department of Specialized Care (DAE / MS) for analysis that would determine the continuation or suspension of accreditation, based on compliance or not the standards established by ordinance, regular reports on the evaluation and annual production. According to the surgeons interviewed, the record could be powered by untrusted data, since they would have among their purposes to support maintenance or suspension of accreditation.

Unfortunately, it remains a challenge to be faced in the fight for effective implementation of policies, in which universal access to effective and resolution should be a guarantee. Overcoming the gap between rule and practice is the way to go for multithreaded interested in solving the ills of this population as specific, as is the scope of notorious intentions contained in ordinances.

The universality, comprehensiveness and equity of health care shall be the goal of health policies that propose to be inducing quality healthcare.

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