Operationalising equity: A study of the challenges in aligning policy principles with performance metrics in Brazilian primary care
1
Brazilian Center of Analysis and Planning, São Paulo, Brazil
Popul. Med. 2026;8(Supplement Supplement 1):A1326
ABSTRACT
BACKGROUND:
The establishment of Brazil’s universal, unified health system (SUS) in 1988 represents the culmination of successful social mobilisation around the right to health. Founded on principles of equity, universality, and comprehensiveness, the SUS has progressively expanded , with significant gains in access and reductions in population-level health disparities(1–3). Nonetheless, significant inequalities persist, particularly within cities(4,5). Concurrently, Brazil’s public sector has undergone extensive reform inspired by New Public Management, emphasising efficiency and performance-based accountability. In primary care, reform included contracting out of public services to non-state providers. Management contracts shape provider behaviour, influence resource allocation, and mediate how policy objectives are translated into everyday practices.
METHODS:
We examine how far equity—an overarching normative principle of the SUS informing primary care policies —is operationalised in management contracts. We developed a conceptual framework of equity grounded in national policy and the global health equity literature(6–11) and applied it to the analysis of performance contracts between municipal governments and non-state primary care providers in São Paulo and Fortaleza, two cities with extensive yet distinct approaches to contracting and performance management. Indicators were systematically examined to assess the degree to which they explicitly or implicitly incorporate equity considerations in the organisation and delivery of primary care.
RESULTS:
In both cities, service volumes dominate performance indicator systems. While such measures are important for assessing inequalities in service access, other dimensions of equity—particularly sociocultural aspects of care, mechanisms for social participation, and welcoming reception and care—are largely neglected.
CONCLUSIONS:
A technical approach to evaluation, where accountability inheres in compliance with centrally defined and easily quantifiable targets(12), risks reproducing inequalities by under-appreciating localised determinants of health and citizen priorities. We call for further research examining how foundational health system principles can be effectively operationalised in service delivery models.
The establishment of Brazil’s universal, unified health system (SUS) in 1988 represents the culmination of successful social mobilisation around the right to health. Founded on principles of equity, universality, and comprehensiveness, the SUS has progressively expanded , with significant gains in access and reductions in population-level health disparities(1–3). Nonetheless, significant inequalities persist, particularly within cities(4,5). Concurrently, Brazil’s public sector has undergone extensive reform inspired by New Public Management, emphasising efficiency and performance-based accountability. In primary care, reform included contracting out of public services to non-state providers. Management contracts shape provider behaviour, influence resource allocation, and mediate how policy objectives are translated into everyday practices.
METHODS:
We examine how far equity—an overarching normative principle of the SUS informing primary care policies —is operationalised in management contracts. We developed a conceptual framework of equity grounded in national policy and the global health equity literature(6–11) and applied it to the analysis of performance contracts between municipal governments and non-state primary care providers in São Paulo and Fortaleza, two cities with extensive yet distinct approaches to contracting and performance management. Indicators were systematically examined to assess the degree to which they explicitly or implicitly incorporate equity considerations in the organisation and delivery of primary care.
RESULTS:
In both cities, service volumes dominate performance indicator systems. While such measures are important for assessing inequalities in service access, other dimensions of equity—particularly sociocultural aspects of care, mechanisms for social participation, and welcoming reception and care—are largely neglected.
CONCLUSIONS:
A technical approach to evaluation, where accountability inheres in compliance with centrally defined and easily quantifiable targets(12), risks reproducing inequalities by under-appreciating localised determinants of health and citizen priorities. We call for further research examining how foundational health system principles can be effectively operationalised in service delivery models.
| eISSN: | 2654-1459 |
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