The Unified Health System in the Federal District, Brazil (1960 to 2018): revisiting history to plan the future.
The current context of the Federal District (DF) health system requires, to be understood, to resume the motivations to change the country's capital. Brasilia, which turned 58 in 2018, is a young municipality, with challenges accumulated throughout its existence. Incidentally, its construction constituted the meta-synthesis n. 31, as an addition to the Plan of Goals of Brazilian president Juscelino Kubitschek and took less than four years to be completed (1,2). This record time was only possible because all there was of knowledge, materials and workforce necessary for the project of the new capital would be gathered here, in the badlands of the Central Plateau.
The new DF was officially inaugurated on April 21, 1960, where Brasilia is located, which has peculiar characteristics to a city constructed to be the Capital of the Country, quite different from Rio de Janeiro, the cultural and political metropolis that preceded it by more than 150 years (3). In that context, the health system of the Federal District was a pioneer in meeting the health needs of the resident population, without any official discrimination from 1960 until the institution of the Unified Decentralized Health System (SUDS) in 1988, succeeded by the Unified Health System (SUS), when universality of care was established throughout the national territory and for the entire population resident in Brazil, through the 1988 Federal Constitution (4) and Laws n. 8,080 (5) and 8,142 (6) of 1990.
Although DF's health system was created together with the city inauguration, its current formation occurred through a particular process and under the direct influence of the SUS development. Therefore, this article aims to describe the trajectory of the health system of the Federal Capital in the period between its foundation and the last administrative year, between 1960 and 2018, and identify the challenges to expand the capacity of health care protection and promotion of the DF population. Although more descriptive than analytical, this work is based on studies of public policy analysis, defined as the evaluation of governments in action or the study of the set of actions that governments carry out (7).
The analysis sought to identify the main mechanisms that guided the course of the political actions without, however, extending the explanation of the difficulties related to the changes and the complexity that the local health policy acquired over time (8). The rescue of this historical process can disclose the endogenous and exogenous elements that favor or not the change or inertia of health policies (9), especially those present in the creation of the Unified Health System of the Federal District (SUS-DF).
A documentary research and non-exhaustive literature review were carried out. The documentary analysis consists of the technique of analyzing original documents, which have not yet received analytical treatment by any author (10). The following were included in the research: management reports, District Health Plans, ordinances and internal regulations of the State Health Secretariat of the Federal District (SHS-DF) that regulated programs, actions and services, publications on the local health policy. The search for the documents was carried out in the physical and digital collection in the SHS-DF library network and the articles, in the Virtual Health Library and Scientific Electronic Library Online.
The historical periods were defined according to the government terms, and in each of these periods the factual information on actions and interventions were collected according to the following categories: health care organization, depicted in Figure 1; training and development of health personnel, shown in Figure 2; and health system management, which can be seen in Figure 3.
Secondary data were also collected from the official information systems on indicators that showed the evolution of the living conditions of the Federal District population--Life expectancy at birth and Infant Mortality, as well as indicators of service provision and population growth (Tables 1 and 2).
Period from 1960 to 1994: service planning and infrastructure
In the period between 1960 and 1994, the DF was administered by mayors and/or governors appointed by the President of the Republic, the so-called "bionic" governments. With the Federal Constitution of 1988, the DF became politically autonomous and elected its first governor in 1990 (4). From the first foundations to raise the city, its fancy constructions and housing and service blocks, health care here would have to be destined to all who needed care, universal care as it is today, since there was no other provider rather than the entrepreneurial government of the largest construction site in the country. Although this was the case, starting with Hospital Presidente Juscelino Kubitschek, currently the Candanga Memory Museum, the practice of universality faced several difficulties, including corporate ones, characterized as units for the treatment of workers, such as the Presidente Medici Hospital, currently Hospital Universitario de Brasilia (2,11).
At the inception of the Federal District Health System (Figures 1 and 2), two plans were important in defining what we still have nowadays: the General Plan of the Hospital-Medical Network of Brasilia, known as Bandeira de Mello Health Plan of 1960 and the Health Care Plan of 1979 (11-14). The Bandeira de Mello Health Plan (12) proposed the organization of a health system with the following configuration: a) elimination of the multiplicity of health care organs; b) distribution of health centers and hospitals per population groups; c) cost reduction and increased efficiency of services resulting from the merging of services; d) convenience for the population, avoiding displacements; e) user's free will in choosing the physician who would treat their health; f) physicians would be paid by productivity; g) full-time employment regime; h) possibility of medical care for private patients; i) participation of the population in problem-solving through the Community Health Councils; k) convalescent home care services, avoiding lengthy hospital stays.
The Bandeira de Mello Plan had as its principles, the structuring of health services with a clear separation between the areas of executive and normative organ actions, obtained through the creation in 1960 of the Fundacao Hospitalar do Distrito Federal(FHDF) as a central administration organ. After 1981 onward, with the creation of the State Health Secretariat of the Federal District (SHS-DF), both entities managed the health system until 1999, with the first being responsible for executive and operational activities; and the second, for the creation of health policies. The planning included the construction of a "high-complexity" hospital (currently Hospital de Base do DF), eleven general hospitals and six rural hospitals, surrounded by satellite units capable of providing assistance to a population of 500,000 inhabitants (11-17). The guidelines aimed at treating the people in several clinical specialties, stimulating patient turnover and reducing hospital length of stay (12, 14).
The plan proposed by Jofran Frejat in 1979 (13), inspired by the UK National Health System (NHS) and the Alma Ata ideals, proposed Primary Health Care (PHC) as a strategy for expanding coverage and population access to health services, with the provision of primary health care units in rural (rural units) and urban areas (health centers). However, due to the scarcity of physicians with generalist training following the example of the General Practitioners of that country, PHC was organized through doctors with specialized training in Gynecology, Pediatrics, Internal Medicine, plus epidemiologists and sanitarians to work in Health Centers for each 30,000 inhabitants (13). This characteristic would represent the resistance of the medical corporation to the idea of PHC, considering that it changed the organization of the profession up to that moment, creating different technical and social valuations among the specialties (17). It also predicted the construction of regional hospitals in each "satellite city" and preserved the high-complexity hospital of the previous Plan. Its principles comprised the hierarchy of care, referral and counter-referral, as well as the regionalization of services. At its implementation, the hiring of health professionals was significantly increased, as well as service provision, especially in PHC, with a consequent improvement in indicators, particularly those related to infant and maternal mortality (13, 14).
During this period, 12 general hospitals and at least 60 Basic Health Units (BHUs) were created, named Health Centers, Rural Health Units and Urban Health Units, which were differentiated by the staff profile and services provided, with Health Centers having a more comprehensive staff (12-14). Public entities were also created and implemented for the management and supply of basic health system services, such as the Central Laboratory, created in 1978 (formerly the DF Health Institute) and the Hemocentro Foundation, created in 1991 (18).
For the training of health personnel, the creation of the School of Nursing Aides of Brasilia (EAEB) in 1960, transformed in 1973 into the Technical School of Health of Brasilia (ETESB) was the highlight. The first specialized medical training initiatives also took place, through courses for the technical improvement of these professionals, in the Hospital Distrital de Brasilia (HDB) in 1960, with the objective of attracting recently graduated medical professionals and six-year undergraduate medical students to the city (14, 19). In 1964, the creation of the Medical Residency and Internship system was officially established through Resolution N. 37/64 of May 11 of that same year. In that year, the first professionals, who would comprise the first official medical residency class in 1966, started their studies (14, 19).
Period from 1995 to 2002--the changes in DF Primary Care and the training of the health personnel
The period from 1995 to 2002 comprised two terms of elected governors for the DF. In the field of health, this period was highlighted by proposals of changes in PHC organization aiming at increasing the population's coverage and changing the care model. The period from 1995 to 1998 are highlighted, with the implementation of the Home Health Program (PSC), which would be equivalent to the former Family Health Program, later called the Family Health Strategy.
In 1995, the Instituto Candango de Solidariedade (ICS) was created to develop social projects associated to government sectors, with the First Lady of the Federal District as its president (17). This entity was responsible for supporting the implementation of the PSC in the period 1996-1999. This way of implementing PHC in the DF differs regarding two respects: it changed the model of primary care developed until that moment and created a nongovernmental entity responsible for the physical infrastructure, installation of teams and hiring of health professionals (17).
The management of DF's health system was also subject to remodeling in this period, through the public administration reforms supported by the Federal Government, which culminated in the process of the FHDF deactivation in 2000. With that, the executive, control and evaluation functions became the responsibility of the SHS-DF.
Another important milestone in the Federal District health management was the creation, in 2000, of the Federal District Constitutional Fund (FCDF), through Law N. 10,633, dated of December 27, 2002 (20). The FCDF consists of government budget resources, which are intended for the entire funding of public security and partially of public health and education in the Federal District.
Regarding In the training and development of health personnel (Figure 3), the creation of Fundacao de Ensino e Pesquisa em Ciencias da Saude (FEPECS (21)), the Escola Superior de Ciencias da Saude (ESCS) and the Medical Course in 2001 are highlighted. This Foundation became responsible for the maintenance of the ETESB and the ESCS, both responsible for the training of professionals at technical, undergraduate, postgraduate and extension and permanent education levels in health. The schools, in turn, stand out for the development of educational activities, integrated to the services and the community, having the SHS/DF units themselves as actual teaching scenarios and, consequently involving the health professionals working there (22). Still in the field of training, in 1997, under Instruction N. 16, dated of 08/05/1997, within the scope of the FHDF, we highlight the creation of the Professional Education programs, analogous to the Residency Program for physicians, for Nursing, Nutrition, Dentistry, Mental Health and Physical Therapy professionals (23).
Period of 2003 to 2010--the changes in the health system management
During the period of 2003 to 2010, there were two terms of elected governments in the Federal District, and the 2007-2010 period was interrupted in 2009, due to signs of corruption. The elected governor was initially replaced by the Speaker of the Legislative Chamber in 2009 and another Governor was elected by indirect elections in 2010.
In the health system management field, the first experience of managing public health services was implemented through the Social Health Organization (OSS). It consists of the Hospital Regional de Santa Maria, which was managed by the Real Sociedade Espanhola de Beneficencia (RSEB), the object of the Management Contract n. 1/2009--SHS-DF, which lasted until 2010. Incidentally, this experience was analyzed and did not prove to be advantageous from the point of view of cost reduction, with great difficulties related to the process of contract performance monitoring, being interrupted rather abruptly at the end of 2010 (24).
Another important initiative of the SHS-DF, which has been under development since 2010, is the Program for Progressive Decentralization of Health Actions (PDPAS), created through Decree n. 31.625/2010 (25), with the objective of assigning greater responsibility and managerial autonomy to the managers of Health Regions and Health Units.
The operation is carried out through the transfer of funds for the purpose of acquiring consumer material and medications, permanent materials and equipment, repairs to physical facilities, the hiring of services of legal entities and individuals, in accordance with legal regulations.
The use of these resources is prohibited for the payment of personnel expenses, taxes, bonuses, parties and receptions, travel and accommodation expenses, infrastructure works, except for minor repairs of structure, acquisition of vehicles, rental of computer equipment and advertising. The program limits the acquisitions by the amount of the expenses, as defined in Law N. 8.666/93 (25).
In the field of personnel training, the creation of the Nursing course at the ESCS, which carried out the first National College Entrance Exam in 2009, was outstanding in this period. Similar to the medical course, the pedagogical project and the curriculum are guided by active teaching-learning methodologies and teaching-service integration, with teachers being selected among health professionals, especially nurses, with an-employment relationship with SHS-DF.
Period of 2011 to 2018--new changes in the management of hospitals and primary health care
In the period of 2011 to 2018, the sixth (2011 to 2014) and seventh (2015 to 2018) elected governments took office. In the health field, the most significant changes occurred in the implementation of new management models in two hospitals and a new change in the PHC organization.
Significant changes also occurred in the Health Regions of the Federal District with the creation of Superintendences responsible for the management of health networks in each of these territories and the establishment of goals and results between the Superintendences of Health Regions and the Central Administration of the SHS-DF (15) (Figure 2).
In 2011, the implementation of Hospital da Crianca de Brasilia Jose Alencar (HCB) was started, through a management agreement signed between SHS-DF and the Institute of Childhood Cancer and Specialized Pediatrics (ICIPE), a Social Organization created by the Brazilian Association of Assistance to Families of Children with Cancer and Hemopathy (ABRACE), especially for the purpose of managing HCB (26).
In 2017, the HBDF was transformed into an Autonomous Social Service and became known as the Instituto Hospital de Base (IHBDF), according to Law N. 5,899 of 2017 (27).
The creation of this entity was motivated by the need to grant autonomy to the management of resources, in the acquisitions and hiring of personnel necessary for its operation, maintaining the public characteristic of all its actions.
In the period from 2015 to 2018 actions were taken to reorganize the PHC, with the aim of changing the configuration that had existed since the mid-1990s, of the coexistence of two models of PHC: BHUs with services organized through medical specialties and scheduled agenda that prevailed in the Pilot Plan and some Administrative Regions; and the FHS, organized according to principles of clientele assignment, family approach, linkage and longitudinality, among other principles, present in most Administrative Regions with greater social vulnerability (17, 28, 29).
As milestones of these initiatives, one can cite SHS-DF Ordinance N. 77 (30), which establishes the norms and guidelines of the Primary Health Care Policy of the Federal District, and SHS-DF Ordinance N. 78 (31), which regulates Article 51 of Ordinance N. 77, by defining the conversion process from the PHC to the FHS model. The reorganization actions included the remodeling of the work process, the hiring and qualification of professionals, the extension of days and hours of BHU operation, among other changes.
This proposal was formulated in 2016 and 2017, as a complement to the "Brasilia Saudavel Project" (32), presented in 2016, which proposed a set of actions to strengthen the PHC and the Emergency Care Units (UPAS), through the hiring of OSS, similar to experiences of other Brazilian municipalities.
This proposal, however, was not fully approved by the DF Health Council (CSDF), especially the expansion of OSS participation in the management of health units. As a result, the CSDF created a Reform Committee for the Care Model / Management of Primary Health Care of the Federal District through CSDF Resolution N. 464 of 07/12/2016 (33), which proposes guidelines that were summarized in CSDF Resolution N. 465 / 2016 of 10/24/2016 (34). In Article 7 of this resolution, the CSDF limits the participation of public and private entities in the management of UPAS, providing that the actual need is justified. To identify and recognize the complementary characteristic of the Emergency Care Units (UPAs) in the health network of the Federal District, through an individual analysis of the characteristics of care in each service, in order to justify the adoption of alternative management models within the existing legal framework, with the possibility of establishing partnerships through a management contract with specialized entities, public or private, including educational institutions (35).
Regarding the training and development of health personnel, there was a significant expansion of medical residency programs and the creation of the first multiprofessional health and network residency-equivalent programs in the SHS-DF, under the coordination of ESCS/FEPECS. In addition, stricto sensu graduate programs were created at ESCS, in addition to the Professional Master's Degree Program in Health Sciences in 2012 and the Academic Masters' Degree in Health Sciences in 2016, as well as the Interinstitutional Doctorate Program in 2016, between ESCS and Faculdade de Ciencias da Saude of Universidade de Brasilia. Previously, ESCS had been responsible for the Interinstitutional Master's Degree program with UNESP of Botucatu, which promoted institutional learning and favored the creation of their own programs (34).
In 2014, the Escola de Aperfeicoamento para o SUS (EAPSUS), was created, responsible for organizing courses corresponding to the needs pointed out by SHS-DF managers. This school has a strong role in the qualification of the clinical practice of professionals through the organization of permanent education activities, in which experienced professionals, with recognized experience in service provision and willing to share their knowledge, work as instructors in theoretical-practical activities that continuously increase, constituting learning communities (34).
Evolution of the population's health conditions and the provision of services
In 2017, the Federal District had a population size estimated by Instituto Brasileiro de Geografia e Estatistica (Brazilian Institute of Geography and Statistics--IBGE) of approximately three (3) million inhabitants, plus approximately two (2) million residents in the municipalities of the Integrated Development Region of the Federal District and Surrounding Areas (RIDE) (Complementary Law n. 94 of 1998) (28). SUS-DF has a network of its own, offering comprehensive care and services of different technological densities.
In 2018, there are 7962 available beds, of which 4482 (56.2%) are SUS-DF beds, belonging to 16 hospitals. PHC is developed in 168 BHUs, with 540 FHS teams, of which coverage reaches more than 2 (two) million inhabitants (68% of the resident population). There are 06 (six) UPAS and 14 (fourteen) regional laboratories, among several points of care, in addition to the associated units, such as: Hemocentro Foundation, Central Laboratory, FEPECS and CSDF (28).
The management of the public health system of the Federal District has the SHS-DF as its main entity, supporting and carrying out the different management activities, such as funding, planning, procurement and hiring of professionals. The funding is mostly provided by the local government's own resources, plus the transfer of resources from the Ministry of Health (MoH) and FCDF (22, 34).
Over time, the health conditions of the DF population favorably changed, according to infant mortality and life expectancy at birth indicators (Table 1). Infant mortality decreased from 28.88 to 11.2 deaths per 1,000 live births from 1990 to 2017. On the other hand, life expectancy at birth increased from 68 years in 1993 to 77 years in 2013. These data indicate improvement of living conditions in the country's capital city.
When evaluating the data that characterize the public supply of health services in the Federal District (Tables 1 and 2), one can observe a significant population growth, but not an equal measure of growth in the supply of services when measured by beds per 1,000 inhabitants, which was constant throughout the period, despite the increase in the absolute number of hospitals and beds (34).
Regarding PHC, Table 2 shows that 277 FS teams were implemented in 1998, reaching 50.91% of population coverage. In the following year it decreased to 22.6%, followed by 10.5% in 2000, reaching 0% coverage in 2003. The recommencement of FHS implementation occurred in 2004, but only in 2108 the 1998 levels of coverage were reached once again (544 teams and 68% of population coverage). The ratio of doctors per 1,000 inhabitants, considering only those hired as public servants, increased in the period, as well as that of nurses.
In this retrospective of the 58 years of the creation of the Public Health System in the Federal District, the characteristics of path dependence (8, 9) can be identified, going from moments in which the original idea reinforcement mechanisms overlap, and moments in which proposals for changes in the policy trajectory to overcome limitations are presented in its ability to promote, prevent, assist and restore the health of the population (15, 17, 29).
The implementation of the first plans for the organization of the Federal District health system resulted in the creation of most of the physical infrastructure of health services that are currently available in the Federal District. Emphasis is placed on the construction of large hospitals that have been maintained for at least 20 years, adding to these units all other strategies, such as the training of professionals, the incorporation of technologies, the way the system is managed and how health care is thought of. Since the 1980s, under the influence of new concepts and national and international guidelines, the emphasis has been placed on plans to strengthen PHC, to expand the population's access to services, and to promote innovative changes in the care model (17, 29, 36, 37).
The PHC inclusion in the health policy agenda of the DF took place in the background and has undergone consecutive initiatives to change its organization during the subsequent government terms since 1994, when the Ministry of Health adopted the Family Health Strategy as the main model of PHC reorganization. Local political efforts then started to seek strategies to incorporate into the work's routine actions and services based on the recognition of the population's needs, apprehended from the establishment of relations between service users and health professionals, in permanent contact in the territory (36), characteristic of the FHS model.
It is noteworthy that in the last four years one dared to promote the restructuring of PHC through the existing structures, without the inclusion of intermediary entities for the hiring of professionals, a recurrent practice in previous moments and in other Units of the Federation (17). Moreover, the debates and expositions of this measure promoted by the local press and by the instances representing health discussion arenas, particularly the CSDF, have attracted the attention from important sectors of the population, which might (re)politicize the demonstrations in favor of SUS-DF.
Regarding the health system management, attention was drawn to the deactivation of the FHDF, which promoted the accumulation of operational and policy-making functions by the SHS-DF. The effects, although scarcely evaluated, include the difficulty of coordination, fragmentation and slowness in the acquisition operation, with the decision-making centralization in relation to budgetary-financial and human resources management. This predominant characteristic in the DF health system is in constant conflict with the strong decentralization in the provision of services in the Health Regions and Units, which are at risk, consume the supplies and that solve the health problems of the population (17).
The SHS-DF administrative centralization has been credited with the main difficulties in supplying inputs, hiring of personnel in a timely manner and overall maintenance. This characteristic has also justified many projects that either go to public-private partnerships, or focus on administrative decentralization/deconcentration, such as the PDPAS (25) and the Regionalized Health Management Program (15). There is not, however, a more in-depth analysis of other exogenous factors that imply difficulties in public health management, such as the likely budget deficit, the already known excesses by the control bodies, and the exhaustion of the Brazilian Bidding Law.
This scenario raises an important question: how to solve the contradiction between the accumulated centrality of health policy formulation and operationalization and the decentralization of services, given the current subdivision of the DF in Administrative Regions, according to its Organic Law. It is important to evaluate the decentralization processes that have already been carried out in the Federal District and in other Federal Units to build evidence that can contribute to future decisions.
The experiences of health personnel training and development in the Federal District represent a powerful innovation vector in health and education. Although their origin is characterized by the dichotomy between technical training and intense medical specialization, the initiatives that unfolded since the 2000s, especially since the creation of the ESCS and the medical and multiprofessional residency programs, demonstrate the viability of the professional formation guided by the deep teaching-service-community integration, which are capable of contributing to the consolidation of SUS, since they associate the understanding of the objective and subjective aspects of human health to the daily practices and health services (22).
This experience is also fruitful regarding the production of new knowledge and new public policies and has been an inspiration for other sectors, such as education and public security (8, 9).
The quick assessment of the infant mortality and life expectancy at birth indicators shows there were improvements in the general living conditions of the population over the period of 1990 to 2017. On the other hand, the service provision indicators show the existence of assistance gaps related to hospital care and the instability in the population coverage by PHC, which has been well documented in the literature (17, 29).
Thus, what can be observed in the SUS-DF trajectory is that a health system has been created here, one that considers the peculiarities of the DF as the country's capital, influenced by contingent (exogenous) factors, such as the demographic, nutritional, epidemiological transition and technological innovations (37), but showing the slow velocity of this system in adapting to these changes through internal reforms (organizational culture, organizational arrangements, assistance models, funding models, incentive systems and leadership) (37).
The DF health system has a complex organization, with different legal entities, purposes and health service deliveries to the population, including those that develop assistance activities of different complexities to the ones that deal with education, research and scientific development, which constitutes its strength. Moreover, the rapid examination of the SUS-DF trajectory shows that the structures and experiences of health personnel training and development with multi- and interdisciplinary characteristics and integrated health management and services, when well-coordinated, can provide feedback and drive the local public health system towards a new cycle focused on the population and their needs.
LBD Gottems an AMB Raggio--worked on the study's concept, design, data collection, analysis and interpretation, writing the manuscript and its critical review; MO Almeida--worked on the study's concept, design, data collection, analysis and interpretation; RJ Bittencourt--worked on the manuscript's critical review and approval of the version to be published.
(1.) Oliveira LL. A construcao de Brasilia. [acessado 2018 Jun 14]. Disponivel em: http://cpdoc.fgv.br/producao/ dossies/JK/artigos/Brasilia/Construcao.
(2.) Lassance A, Lopes CNS, Farias DD, Silva DC, Pereira MM. Brasilia: Capital do Brasil. Brasilia: Instituto Historico e Geografico do Distrito Federal, Porfiro; 2003.
(3.) Campos CEA, Cohn A, Brandao AL. Trajetoria historica da organizacao sanitaria da Cidade do Rio de Janeiro: 1916-2015. Cem anos de inovacoes e conquistas. Cien Saude Colet 2016; 21(5):1351-1364.
(4.) Brasil. Constituicao da Republica Federativa do Brasil. Brasilia: Centro Grafico do Senado Federal; 1988.
(5.) Brasil. Lei Federal no. 8.080, de 19 de setembro de 1990. Dispoe sobre as condicoes para a promocao, protecao e recuperacao da saude, a organizacao e o funcionamento dos servicos correspondentes e da outras providencias. Diario Oficial da Uniao 1990; 19 set.
(6.) Brasil. Brasil. Lei Federal no. 8.142, de 28 de dezembro de 1990. Dispoe sobre a participacao da comunidade na gestao do Sistema Unico de Saude (SUS) e sobre as transferencias intergovernamentais de recursos financeiros na area da saude e da outras providencias. Diario Oficial da Uniao 1990; 28 dez.
(7.) Souza C. "Estado do campo" da pesquisa em politicas publicas no Brasil. Rev. Bras. Ci. Soc. 2003; 18:15-20.
(8.) Kay A. A critique of the use of path dependency in policy studies. Public Administration 2005; 83(3):553-571.
(9.) Kwamie A, Dijk HV, Ansah EK, Agyepong IA. The path dependence of district manager decision-space in Ghana. Health Policy and Planning 2016; 31(3):356-366.
(10.) Sa-Silva JR, Almeida CD, Guindani JF. Pesquisa documental: pistas teoricas e metodologicas. Revista Brasileira de Historia & Ciencias Sociais 2009; 1(1):1-15.
(11.) Kaniak CEA. Plano Geral da Rede Medico-Hospitalar para o Distrito Federal de Henrique Bandeira de Mello. Rev Saude Dist Fed 1999; 10:52-53.
(12.) Melo HB. Plano Geral da Rede Medico-Hospitalar de Brasilia. Revista do Servico de Saude Publica 1959; XI(1).
(13.) Frejat J. Sistema de saude do DF: modelo para o pais. Rev Saude Dist Fed 1999; 10:53-59.
(14.) Silva E. A saga da Fundacao Hospitalar no Distrito Federal: e a medicina da poeira e da lama. Brasilia: Copacabana; 2000.
(15.) Gottems LBD, Raggio AMB, Oliveira A, Roque MV, Bittencourt RJ. A regionalizacao da Gestao da Saude no DF: o caminho para a "ponta" virar centro. Brasilia em Debate 2017; 17:22-27.
(16.) Scartezini M. Hospital Juscelino Kubitschek de Oliveira (Ex-hospital do IAPI). Rev Saude Dist Fed 1999; 10:66-70.
(17.) Gottems LBD. Analise da politica de atencao primaria a saude desenvolvida no Distrito Federal: a articulacao entre o contexto politico, os problemas, as alternativas e os atores na formacao da politica de saude (1979 a 2009) [tese]. Brasilia: Universidade de Brasilia; 2010.
(18.) Camara Legislativa do Distrito Federal. Lei no. 206, de 13 de dezembro de 1991. Autoriza o Governo do Distrito Federal a criar a Fundacao Hemocentro de Brasilia e o Sistema De Sangue, Componentes e Hemoderivados (SSCH) e da outras providencias. Diario Oficial do Distrito Federal 1991; 16 dez.
(19.) Campos VDG. Residencia Medica: Desafios e Perspectivas. Com. Ciencias Saude 2015; 26(1/2):7-8.
(20.) Brasil. Lei no. 10.633, de 27 de dezembro de 2002. Institui o Fundo Constitucional do Distrito Federal--FCDF, para atender o disposto no inciso XIV do art. 21 da Constituicao Federal. Diario Oficial da Uniao 2002; 30 dez.
(21.) Camara Legislativa do Distrito Federal. Lei no. 2.676, de 12 de janeiro de 2001. Cria a Fundacao de Ensino e Pesquisa em Ciencias da Saude e da outras providencias. Diario Oficial do Distrito Federal 2001; 15 jan.
(22.) Silva VO, Santana PMMA. Conteudos curriculares e o Sistema Unico de Saude (SUS): categorias analiticas, lacunas e desafios. Interface (Botucatu) 2015; 19(52):121-132.
(23.) Mineto RC. Residencia em enfermagem do Hospital de Base do Distrito Federal: avaliacao dos ex-residentes. Com. Ciencias Saude 2008; 19(2):155-162.
(24.) Nascimento ICR. A experiencia do contrato de gestao no DF: o caso do Hospital Regional de Santa Maria [monografia]. Brasilia: Universidade de Brasilia; 2011. [acessado 2018 Jun 14]. Disponivel em: http://bdm.unb.br/ bitstream/10483/2837/6/2011_Isabel CristinaRigottidoNascimento.pdf
(25.) Governo do Distrito Federal. Decreto no. 31.625, de 29 de abril de 2010. Institui o Programa de Descentralizacao Progressiva de Acoes de Saude (PDPAS) para as Diretorias Regionais de Saude e as Unidades de Referencia Distrital da Rede Publica de Saude do Distrito Federal. Diario Oficial do Distrito Federal 2010; 30 abr.
(26.) Governo do Distrito Federal. Secretaria de Estado da Saude do Distrito Federal. Plano Distrital de Saude 2016-2019. Brasilia; 2016 [acessado 2018 Jun 14]. Disponivel em: http://www.saude.df.gov.br/wp-conteudo/uploads/2017/11/PDS_2016-2019_OFICIAL_ Parte_I-1.pdf
(27.) Camara Legislativa do Distrito Federal. Lei no. 5.899, de 03 de julho de 2017. Autoriza o Poder Executivo a instituir o Instituto Hospital de Base do Distrito Federal --IHBDF e da outras providencias. Diario Oficial do Distrito Federal 2017; 4 jul.
(28.) Distrito Federal. Secretaria de Estado da Saude do Distrito Federal. Relatorio Anual de Gestao. Brasilia; 2017. [acessado 2018 Jun 14]. Disponivel em: http://www. saude. df.gov.br/wp-conteudo/uploads/2017/11/RAG2016-Parte-I.pdf
(29.) Gottems LBD, Evangelista MSN, Pires MRGM, Silva AFM, Silva PA. A trajetoria da politica de atencao basica a saude no Distrito Federal. Cad Saude Publica 2009, 25(6):1409-1419.
(30.) Distrito Federal. Secretaria de Estado da Saude. Portaria no. 77, de 14 de fevereiro de 2017b. Estabelece a Politica de Atencao Primaria a Saude do Distrito Federal. Diario Oficial do Distrito Federal 2017; 15 fev.
(31.) Distrito Federal. Secretaria de Estado da Saude. Portaria no. 78, de 14 de fevereiro de 2017. Regulamenta o art. 51 da Portaria no. 77, de 2017, para disciplinar o processo de conversao da Atencao Primaria a Saude do Distrito Federal ao modelo da Estrategia Saude da Familia. Diario Oficial do Distrito Federal 2017; 15 fev.
(32.) Distrito Federal. Projeto Brasilia Saudavel: fortalecimento da Atencao Primaria a Saude no Distrito Federal. [acessado 2018 Jun 14]. Disponivel em: http://www.coren-df.gov.br/site/wp- content/uploads/2016/06/BRASILIA_SAUDAVEL_DOCUMENTO_REFERENCIAL.pdf
(33.) Distrito Federal. Conselho de Saude do Distrito Federal. Resolucao CSDF no. 464, de 12 de julho de 2016. Diario Oficial do Distrito Federal 2016; 29 jul.
(34.) Distrito Federal. Secretaria de Estado da Saude do Distrito Federal. Relatorio Anual de Gestao. Brasilia; 2017. [acessado 2018 Jun 14]. Disponivel em: http://www.saude.df.gov.br/wp-conteudo/uploads/2017/11/RAG2016-Parte-I.pdf
(35.) Distrito Federal. Conselho de Saude do Distrito Federal. Resolucao CSDF no. 465, de 04 de outubro de 2016. Diario Oficial do Distrito Federal 2016; 24 out.
(36.) Oliveira MAC, Pereira IC. Atributos essenciais da Atencao Primaria e a Estrategia Saude da Familia. Rev Bras Enferm 2013; 66(esp):158-164.
(37.) Mendes EV. 25 anos do Sistema Unico de Saude: resultados e desafios. Estud. Av. 2013; 27(78):27-34.
Article submitted 15/06/2018
Final version submitted 27/03/2019
Leila Bernarda Donato Gottems (https://orcid.org/0000-0002-2675-8085) 
Marilza Oliveira de Almeida (https://orcid.org/0000-0001-7277-4900) 
Armando Martinho Badou Raggio (https://orcid.org/0000-0002-8398-8928) 
Roberto Jose Bittencourt (https://orcid.org/0000-0002-6482-5840) 
 Escola Superior de Ciencias da Saude, Fundacao de Ensino e Pesquisa em Ciencias da Saude. Setor Medico Hospitalar Norte Conjunto A Bl. 01/Edificio Fepecs, Asa Norte. 70710-907 Brasilia DF Brasil. firstname.lastname@example.org
Caption: Figure 1. Chronology of the main organization actions of the DF health care system--1960-2018.
Caption: Figure 2. Chronology of the main changes in the DF health system management of the--1960-2018.
Caption: Figure 3. Chronology of the main health personnel training and development actions of the ESCS/FEPECS/SHSDF --1960-2018.
Table 1. Supply of health services, infant mortality, maternal mortality and life expectancy at birth in the DF. Brasilia-DF, 2019. Year 1993 2000 2010 Population 1,657,841 2,043,169 2,570,160 N. of public hospitals 11 13 15 Operational beds 2,727 2,706 4,338 N. beds/1000 inhab/year 1.6 1.3 1.7 N. of physicians 2,570 4,683 Mean/1,000 inhab 1 2 N. of Nurses 1,070 2,216 N. of Nurses/1000 inhab 0.5 0.9 Child Mortality Rate ** 25.43 15.27 12.16 Life Expectancy Rate 68.60 73.20 76.00 N. of maternal deaths / 35.42 45.2 100,000 LB Year 2018 Population 2,972,209 N. of public hospitals 16 Operational beds 4,327 N. beds/1000 inhab/year 1.4 N. of physicians 5,466 Mean/1,000 inhab 2 N. of Nurses 3,547 N. of Nurses/1000 inhab 1.1 Child Mortality Rate ** Life Expectancy Rate N. of maternal deaths / 100,000 LB N. = Number; inhab. = inhabitants; LB = living births Notes: (*) In the period 2017-2018, all Health Centers started to operate as BHUs with Family Health Strategy Teams or Polyclinics, with the exception of 2 units, which continued as support. (**) Source: RIPSA, 2012 (1990-2011) and SHS-DF (2012-017). Data from 2017 are partial. Table 2. Evolution of the supply of PHC health services and population coverage from 1998 to 2018. Brasilia-DF, 2018. Year N.HC No. U/R Total N.FHTs *** % HU of coverage BHUs by FHTs *** 1998 58 27 85 277 50.91 1999 59 24 83 121 22.59 2000 63 29 92 60 10.51 2001 61 30 91 60 9.87 2002 61 30 91 40 6.58 2003 61 31 92 0 0 2004 61 33 94 38 5.99 2005 61 37 98 40 6.3 2006 56 42 98 24 3.55 2007 62 41 103 33 4.77 2008 61 31 92 39 5.64 2009 61 31 92 92 12.41 2010 68 25 93 120 15.87 2011 68 39 107 110 14.77 2012 66 41 107 133 17.58 2013 66 41 107 154 20.06 2014 60 38 98 242 31.52 2015 66 49 115 246 32.04 2016 66 2 68 247 32.17 2017 66 2 68 259 33.74 2018 (*) 2 176 326 68(**) Source: Data extracted from: http://dab.saude.gov.br/historico_ cobertura_sf/historico_cobertura_sf_relatorio.php Legend: HC--Health Centers; U/R HU -Urban and Rural Health Units; FHT--Family Health Teams Notes: (*) In the period 2017/2018, all Health Centers started to operate as BHUs with Family Health Strategy Teams or Polyclinics, with the exception of 2 units, which continued as support. (**) A change was made in the DF, regarding the indicator that measures the population coverage by FHTs, which increased the amount of population per team, which is why there is a divergence between the data extracted from the MoH and the SHS-DF reports.
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|Author:||Gottems, Leila Bernarda Donato; de Almeida, Marilza Oliveira; Raggio, Armando Martinho Badou; Bitten|
|Publication:||Ciencia & Saude Coletiva|
|Date:||Jun 1, 2019|
|Next Article:||A panorama of the health situation in Brazil's Federal District, 2005 to 2017.|