Cervical cancer is reported to be the first among the five leading cancers affecting women in South Africa and the leading cancer among Black females. There is a high incidence and mortality rate among underserved and under-screened women presenting with cervical cancer as they are often unable to access screening facilities. Very little has been done to establish the factors in private health care provision that influence the implementation of cervical screening programmes. The study investigates factors influencing cervical cancer screening programme implementation among private medical practitioners in Soshanguve to establish whether private practitioners assume their roles in cervical screening. The intention is to provide guidelines for a screening programme that could be implemented in private health facilities. The study is qualitative, explorative, descriptive and contextual, using interviews and observation as the main data-collection methods. Lack of awareness and interest, failure to inform patients about cervical screening, age and gender of medical practitioners were among the factors identified. The study concluded that awareness programmes about cervical screening and materials containing information on cervical cancer and predisposing factors should be designed. The utilization of cheaper laboratory service providers could increase participation by making the test affordable and accessible to cash patients. The establishment of a private Pap clinic within medical practices or even as an independent entity is also recommended. / Health Studies / M.A. (Public Health)

O desenvolvimento de Unidades de Terapia Intensiva Pediátrica (UTIP) aumentou a sobrevida de pacientes graves, que passaram a receber alta das UTIP e, conseqüentemente, aumentou o número de doenças crônicas sequelares. A proposta deste trabalho é identificar se houve diminuição da expectativa média de vida das crianças, após cinco anos de alta da UTIP, quais tipos de co-morbidades apresentam e identificar alterações no desempenho escolar, observando se necessitam de escola regular ou especial, os índices de reprovação e abandono escolar, correlacionando-os com situação sócio-econômica, doença da internação e tipo de atendimento prestado, público ou privado, no momento da internação. A pesquisa iniciou identificando as crianças internadas na UTIP da Santa Casa de Maringá, que possui atendimento misto (SUS E NÃO SUS), desde que, no momento da internação, apresentassem mais de vinte e oito dias de idade, ficassem internadas por mais de 24 horas e não evoluíssem para óbito durante a internação. Após seleção, aplicamos dois questionários, o primeiro relacionado à internação, com dados pessoais e clínicos, e o segundo aplicado às famílias das crianças encontradas após cinco anos da alta. Encontramos 84% da amostra, com taxa de sobrevida de 88% e 98% para NÃO SUS e SUS respectivamente. Observamos que 35% das crianças estão em escola especial e 18% com seqüelas motoras. No restante das crianças, o índice de reprovação chega a 45%, com 5% de abandono escolar / The development of Pediatric Intensive Care Units (PICU) increased the survival of critically ill patients, now discharged from PICU, and consequently, increased the number of chronic diseases and sequelae. The purpose of this study is to identify whether there was a decrease of average life expectancy of children after five years of discharge from PICU, what types of co morbidities present and identify changes in school performance, noting if they need regular or special school, the failure rates and dropout, correlating them with socioeconomic status, disease hospitalization and type of care provided, public or private, at the time of admission. The research began by identifying the children admitted to the PICU at Santa Casa de Maringá, which has mixed attendance (SUS AND NON SUS) since, at the time of admission, presented more than twenty-eight days old, stayed in hospital for more than 24 hours and not died during hospitalization. After selection, we applied two questionnaires, the first related to the hospital, with personal and clinical data, and the second applied to childrens families found five years after discharge. We found 84% of the sample, with survival rate of 88% and 98% for NO SUS and SUS, respectively. We observed that 35% of children are at special school and 18% of them with motor sequelae. In the remaining children, the failure rate is about 45%, with 5% of dropout

Background: According to the United Nations AIDS Reference Group (2010) and World Health Organization (2010:2), approximately 33 million people in the world had HIV/AIDS in 2009 of which 2.6 million were children. More than 30 million of these individuals resided in low– and middle–income countries. South–Africa had the highest prevalence of HIV/AIDS in the world with an estimated 5.2 million patients in 2009 (Statistics South Africa, 2010:2). Although the prevalence of human immunodeficiency virus (HIV) infection among children is reported to be high, little is known about other medication administrated concomitantly with their antiretroviral drugs. Objective: The general objective of this study was to investigate possible changes in the medicine prescribing patterns of HIV/AIDS and non–HIV/AIDS children. Methods: A quantitative, retrospective drug utilisation review was performed utilising medicine claims data of a South African pharmacy benefit management company. Data for a four–year period (Jan 1, 2005 to Dec 31, 2008) were analysed. The study population consisted of all children <=12 years divided into those receiving ARVs (designated HIV positive) and those without (designated HIV negative). Descriptive statistics such as average mean, standard deviation, t–test, d–values, and two way frequency tables were used to describe the results. Data were analysed using the Statistical Analysis System ® SAS 9.1 ® programme. Results: The study population (children <= 12 years) represented 16.2% (n = 197 323) of the total population in 2005, 15.4% (n = 193 346) in 2006, 15.6% (n = 142 049) in 2007 and 13.3% (n = 98 939) in 2008. Children with HIV/AIDS represented 0.2% (n = 197 323) of the study population in 2005 and increased to 0.4% (n = 98 939) in 2008, whereas the percentage of children without HIV/AIDS decreased from 99.8% (n = 197 323) in 2005 to 99.6% (n = 98 939) in 2008. The total number of HIV/AIDS children that also received other medication concomitantly with their ARVs increased from 96.5% (n = 402) in 2005 to 97.2% (n = 427) in 2008. Males with HIV/AIDS who used other medication represented 52.6% (n = 388) in 2005 and increased to 53.3% in 2008 while female HIV/AIDS patients represented 47.4% in 2005 and decreased to 46.7% in 2008. Prescriptions containing three ARV items represented 69.5% (n = 2 969) of the total number of prescriptions received by HIV/AIDS patients in 2005 and decreased to 67.7% in 2008. The combination of lamivudine, nevirapine and stavudine were the three products that appeared most frequently on prescriptions for HIV/AIDS children in the age group 0 <= 1 years and 1 <= 5 years from 2005 to 2008. In the age group 5 <= 12 years the combination most frequently prescribed was lamivudine, nevirapine and zidovudine. HIV positive children received 6.2 ± 4.62 prescriptions for other medication (non–ARVs) per year during 2005 compared to HIV negative children with 3.9 ± 3.71 (p < 0.0001, d = 0.5). In 2008 HIV positive children received 6.4 ± 5.02 prescriptions per year compared to HIV negative patients who received 4.36 ± 4.05 prescriptions (p < 0.0001, d = 0.5) in 2008. HIV negative children received more central nervous system items, endocrine items and autacoids than HIV positive children, whereas HIV positive children received more respiratory system agents, dermatological, ear, nose throat and antimicrobials items. Conclusion: The study showed that HIV positive children received significantly more prescriptions for other medication per year compared to their HIV negative counterparts. The top pharmacological groups mostly prescribed to both groups were respiratory agents, antimicrobials, analgesics, dermatological and ear, nose and throat items. / Thesis (M.Pharm. (Pharmacy Practice))--North-West University, Potchefstroom Campus, 2012.

Background: According to the United Nations AIDS Reference Group (2010) and World Health Organization (2010:2), approximately 33 million people in the world had HIV/AIDS in 2009 of which 2.6 million were children. More than 30 million of these individuals resided in low– and middle–income countries. South–Africa had the highest prevalence of HIV/AIDS in the world with an estimated 5.2 million patients in 2009 (Statistics South Africa, 2010:2). Although the prevalence of human immunodeficiency virus (HIV) infection among children is reported to be high, little is known about other medication administrated concomitantly with their antiretroviral drugs. Objective: The general objective of this study was to investigate possible changes in the medicine prescribing patterns of HIV/AIDS and non–HIV/AIDS children. Methods: A quantitative, retrospective drug utilisation review was performed utilising medicine claims data of a South African pharmacy benefit management company. Data for a four–year period (Jan 1, 2005 to Dec 31, 2008) were analysed. The study population consisted of all children <=12 years divided into those receiving ARVs (designated HIV positive) and those without (designated HIV negative). Descriptive statistics such as average mean, standard deviation, t–test, d–values, and two way frequency tables were used to describe the results. Data were analysed using the Statistical Analysis System ® SAS 9.1 ® programme. Results: The study population (children <= 12 years) represented 16.2% (n = 197 323) of the total population in 2005, 15.4% (n = 193 346) in 2006, 15.6% (n = 142 049) in 2007 and 13.3% (n = 98 939) in 2008. Children with HIV/AIDS represented 0.2% (n = 197 323) of the study population in 2005 and increased to 0.4% (n = 98 939) in 2008, whereas the percentage of children without HIV/AIDS decreased from 99.8% (n = 197 323) in 2005 to 99.6% (n = 98 939) in 2008. The total number of HIV/AIDS children that also received other medication concomitantly with their ARVs increased from 96.5% (n = 402) in 2005 to 97.2% (n = 427) in 2008. Males with HIV/AIDS who used other medication represented 52.6% (n = 388) in 2005 and increased to 53.3% in 2008 while female HIV/AIDS patients represented 47.4% in 2005 and decreased to 46.7% in 2008. Prescriptions containing three ARV items represented 69.5% (n = 2 969) of the total number of prescriptions received by HIV/AIDS patients in 2005 and decreased to 67.7% in 2008. The combination of lamivudine, nevirapine and stavudine were the three products that appeared most frequently on prescriptions for HIV/AIDS children in the age group 0 <= 1 years and 1 <= 5 years from 2005 to 2008. In the age group 5 <= 12 years the combination most frequently prescribed was lamivudine, nevirapine and zidovudine. HIV positive children received 6.2 ± 4.62 prescriptions for other medication (non–ARVs) per year during 2005 compared to HIV negative children with 3.9 ± 3.71 (p < 0.0001, d = 0.5). In 2008 HIV positive children received 6.4 ± 5.02 prescriptions per year compared to HIV negative patients who received 4.36 ± 4.05 prescriptions (p < 0.0001, d = 0.5) in 2008. HIV negative children received more central nervous system items, endocrine items and autacoids than HIV positive children, whereas HIV positive children received more respiratory system agents, dermatological, ear, nose throat and antimicrobials items. Conclusion: The study showed that HIV positive children received significantly more prescriptions for other medication per year compared to their HIV negative counterparts. The top pharmacological groups mostly prescribed to both groups were respiratory agents, antimicrobials, analgesics, dermatological and ear, nose and throat items. / Thesis (M.Pharm. (Pharmacy Practice))--North-West University, Potchefstroom Campus, 2012.

Cervical cancer is reported to be the first among the five leading cancers affecting women in South Africa and the leading cancer among Black females. There is a high incidence and mortality rate among underserved and under-screened women presenting with cervical cancer as they are often unable to access screening facilities. Very little has been done to establish the factors in private health care provision that influence the implementation of cervical screening programmes. The study investigates factors influencing cervical cancer screening programme implementation among private medical practitioners in Soshanguve to establish whether private practitioners assume their roles in cervical screening. The intention is to provide guidelines for a screening programme that could be implemented in private health facilities. The study is qualitative, explorative, descriptive and contextual, using interviews and observation as the main data-collection methods. Lack of awareness and interest, failure to inform patients about cervical screening, age and gender of medical practitioners were among the factors identified. The study concluded that awareness programmes about cervical screening and materials containing information on cervical cancer and predisposing factors should be designed. The utilization of cheaper laboratory service providers could increase participation by making the test affordable and accessible to cash patients. The establishment of a private Pap clinic within medical practices or even as an independent entity is also recommended. / Health Studies / M.A. (Public Health)

O desenvolvimento de Unidades de Terapia Intensiva Pediátrica (UTIP) aumentou a sobrevida de pacientes graves, que passaram a receber alta das UTIP e, conseqüentemente, aumentou o número de doenças crônicas sequelares. A proposta deste trabalho é identificar se houve diminuição da expectativa média de vida das crianças, após cinco anos de alta da UTIP, quais tipos de co-morbidades apresentam e identificar alterações no desempenho escolar, observando se necessitam de escola regular ou especial, os índices de reprovação e abandono escolar, correlacionando-os com situação sócio-econômica, doença da internação e tipo de atendimento prestado, público ou privado, no momento da internação. A pesquisa iniciou identificando as crianças internadas na UTIP da Santa Casa de Maringá, que possui atendimento misto (SUS E NÃO SUS), desde que, no momento da internação, apresentassem mais de vinte e oito dias de idade, ficassem internadas por mais de 24 horas e não evoluíssem para óbito durante a internação. Após seleção, aplicamos dois questionários, o primeiro relacionado à internação, com dados pessoais e clínicos, e o segundo aplicado às famílias das crianças encontradas após cinco anos da alta. Encontramos 84% da amostra, com taxa de sobrevida de 88% e 98% para NÃO SUS e SUS respectivamente. Observamos que 35% das crianças estão em escola especial e 18% com seqüelas motoras. No restante das crianças, o índice de reprovação chega a 45%, com 5% de abandono escolar / The development of Pediatric Intensive Care Units (PICU) increased the survival of critically ill patients, now discharged from PICU, and consequently, increased the number of chronic diseases and sequelae. The purpose of this study is to identify whether there was a decrease of average life expectancy of children after five years of discharge from PICU, what types of co morbidities present and identify changes in school performance, noting if they need regular or special school, the failure rates and dropout, correlating them with socioeconomic status, disease hospitalization and type of care provided, public or private, at the time of admission. The research began by identifying the children admitted to the PICU at Santa Casa de Maringá, which has mixed attendance (SUS AND NON SUS) since, at the time of admission, presented more than twenty-eight days old, stayed in hospital for more than 24 hours and not died during hospitalization. After selection, we applied two questionnaires, the first related to the hospital, with personal and clinical data, and the second applied to childrens families found five years after discharge. We found 84% of the sample, with survival rate of 88% and 98% for NO SUS and SUS, respectively. We observed that 35% of children are at special school and 18% of them with motor sequelae. In the remaining children, the failure rate is about 45%, with 5% of dropout

Trata-se de uma pesquisa qualitativa composta por análise bibliográfica categorial com foco em reforma do Estado e regulação, por um levantamento da estrutura do mercado e das atas de reunião da Câmara de Saúde Suplementar (CSS) e por entrevistas semi-estruturadas com os principais atores desta câmara, buscando entender posicionamentos e principais pontos em debate, construindo um quadro de referência do setor, visando identificar sucessos e lacunas do processo. A pergunta central é até que ponto a regulação, a partir do modelo de agência adotado no Brasil para o setor de saúde suplementar, não estaria atingindo os objetivos propostos quando da sua criação, ou seja, de defender o interesse público na assistência suplementar à saúde. O mercado de saúde suplementar é composto por 36,9 milhões de beneficiários de planos de saúde em 2006 representando 19,6% da população brasileira. Apesar do seu tamanho e da relação público-privada que permitiu seu desenvolvimento ao longo do século passado ocorreu à margem de um regramento oficial até 1998, com a promulgação das Leis 9.656/98 e 9.961/00, esta última criando a ANS, estendendo o processo de reconfiguração do papel do Estado para o setor de saúde. Entre 01/2000 e 12/2006 a ANS realizou 25 consultas públicas (4,2 consultas ao ano em média), destas 11 trataram de temas financeiros; enquanto questões cadastrais, de definição de produtos e de contratualização foram temas de três consultas cada. Neste mesmo período a ANS emitiu 790 normativos, uma média de 113 normativos por ano. A comparação entre consultas públicas e normativos sugere uma pequena participação externa à agência no processo de regulação. Desde sua criação em 1998 até 09/2006 a CSS se reuniu 44 vezes, considerando presença relativa (ponderada pelo número de convocações) as representações mais presentes foram: prestadores de serviço, medicinas de grupo, seguradoras, reguladores (ANS) e consumidores com 100%. No pólo inverso foram identificados: trabalhadores, governo e gestores com menos de 55% de presença relativa, sugerindo o grau de importância que cada grupo de representação confere à CSS, seja como fórum de debate ou espaço para disseminação de suas posições. Nestas reuniões foram pautados 129 temas, com predominância daqueles ligados a característica e estrutura da regulamentação (35% dos temas), apresentações da ANS (13% das pautas) e programas da ANS (9% dos temas). Temas como a avaliação da ANS pelos atores e discussão quanto a lacunas no processo de regulação, embora pareçam cruciais para a adequação do modelo, foram tratados apenas uma vez cada. Adicionalmente, a elaboração por parte dos atores da CSS de documentos para discussão foi tema em apenas duas das 129 pautas. As entrevistas com os atores da CSS revelam que há consenso quanto a Reforma do Estado ser a origem da regulação via agência, porém discute-se sua autonomia, distanciamento do controle social do SUS, falta de integração com políticas do Ministério da Saúde, interfaces entre os sistemas público e privado, renúncia fiscal, subordinação entre SUS e sistema suplementar, efetividade dos contratos préregulação e participação (ou interferência) do Judiciário no processo. A maioria das xv representações discute saúde suplementar desde o inicio dos anos 90, sofrendo o desgaste em função do longo período de participação e dos resultados aquém dos esperados. A composição heterogênea, não paritária e o caráter consultivo da CSS dificulta a construção do entendimento. A baixa participação de governo, trabalhadores e gestores e a discussão prévia entre ANS e MS dos assuntos relevantes corroboram com a avaliação de baixa produtividade dada à CSS. Há consenso pela busca de sustentabilidade do mercado, mas com divergências quanto às alternativas para atingi-la, com posicionamentos antagônicos quanto a incentivos fiscais, ressarcimento ao SUS, volume de lucro aceitável e metodologia de apuração dos reajustes de preços. Os gargalos apontados pelos atores foram sistemas e recursos humanos, falta de integração entre as diretorias da agência e o volume de normativos, que são apontados como fatores de lentidão e incremento de custos no processo regulatório. Ressaltam ainda a necessidade de maior participação da sociedade e transparência. São reconhecidos poucos sucessos (definição de produtos, direitos e cobertura, saneamento do mercado e programas de qualificação e troca de informação) e diversas lacunas (adequação do marco regulatório, integração interna da ANS, incorporação do prestador de serviços no campo regulado e integração com o SUS). Conclui-se que a regulação em saúde suplementar atingiu uma fase em que nenhum ator está satisfeito, mesmo entendendo ser este um processo em construção e dadas as divergências de interesses e limitações do fórum de discussão, a construção de consensos via CSS é complexa podendo não ocorrer. Adicionalmente, os posicionamentos e lacunas da agência no processo não permitem enxergá-la como efetiva defensora do interesse público em saúde suplementar. / This qualitative research is composed by a bibliographical analysis focused on state reform and regulation, the market structure analysis, the Câmara de Saúde Suplementar (CSS) meeting minutes analysis and by semi-structured interviews with CSS actors understanding positioning, discussion points, identifying successes and lacking points of the process. The objectives of this thesis are build a frame of reference for the supplementary health market, through a statistical analysis including analysis of the CSS meeting minutes, of the public consultations and rules issued by ANS; as well as analyzing the impacts of regulation on the several groups of interest represented in the CSS, discussing amplitude and range of regulation and questioning ANS mission achievement, as public interest defender in this market. The Brazilian supplementary health market assists 36.9 million beneficiaries, according to 2006 s data, which represents 19.6% of the population. Despite its size and the public-private relationship which allowed its growth since the beginning of last century, it remained unregulated until 1998. Regulatory activity was undertaken by ANS in 2000, extending State role reconfiguration concept to health field. Between 01/2000 and 12/2006 ANS called 25 public consultations (4.2 per year), from which 11 dealt with financial subjects, while masterfile, product definitions and contractualization were subject of 3 consultations each. During this period ANS issued 790 rules, an average of 113 per year. The comparison between the number of public consultations and of rules issued suggests small external participation. Since its creation in 1998 until 09/2006, CSS held 44 meetings. Considering relative participation, the most present representations were service providers, health maintenance groups, insurers, regulators and consumers with 100% of presence. On the other hand health workers, government and public health managers were present to less than 55% of the meetings, suggesting the relative importance given to CSS by each representation. During these meetings 129 different subjects were discussed. Main topics covered were regulation characteristics and structure (35%), ANS presentations (13%) e ANS programs (9%). Subjects as ANS evaluation and lacking points discussion, despite seeming crucial were dealt only once each. Additionally discussion of documents prepared by CSS actors took place only twice. Interviews seeked for actor s positioning on regulation model, were consensus resides on agency origin from state reform process, but autonomy, distance from SUS social control, lack of integration with Health Ministry policies, public and private systems interfaces, tax relieves, subordination of private system to SUS, effectiveness of preregulation contracts and Justice interference in the process are still points of discussion. The majority of representants have being discussing private health issues since the beginning of the 90s, suffering from the stress of long participation with limited results. The uneven composition and consulting status of the CSS are obstacles towards build understanding. Government s, health workers and public health managers low participation in CSS and pre-meeting discussions of relevant xvii subjects between ANS and MS, induce to a low productivity appraisal of CSS. Pursue sustainability seems to be a consensus, although ways to achieve this are discrepant, varying from definition of new fiscal incentives and reimbursement to SUS policy to definition of admited profit margins. ANS s evaluation by actors indicate botlenecks in IT and human resources, lack of integration within the agency s directorships and the amount of rules issued all of with contribute to increase costs and delay the regulatory process. Transparency and participation on decision processes are also claimed for. Few success examples are identified (product, rights and coverage definition, market clearing and implementation of quality programs) and several lacking points are indicated (adequacy of the regulatory base, internal integration, inclusion of the service providers in the regulated field and integration with SUS). Conclusions indicate that regulation has achieved a stage were none of the actors are satisfied, even recognizing that this is still a process in construction, and given the interest discrepancies between actors and limitations of the discussion arena, build consensus via CSS is complex and may not happen. At the same time, the number of lacking points in the regulation process show the distance for ANS to achieve its mission, and therefore do not allow see ANS as effective public interest defender in this market.

Trata-se de uma pesquisa qualitativa composta por análise bibliográfica categorial com foco em reforma do Estado e regulação, por um levantamento da estrutura do mercado e das atas de reunião da Câmara de Saúde Suplementar (CSS) e por entrevistas semi-estruturadas com os principais atores desta câmara, buscando entender posicionamentos e principais pontos em debate, construindo um quadro de referência do setor, visando identificar sucessos e lacunas do processo. A pergunta central é até que ponto a regulação, a partir do modelo de agência adotado no Brasil para o setor de saúde suplementar, não estaria atingindo os objetivos propostos quando da sua criação, ou seja, de defender o interesse público na assistência suplementar à saúde. O mercado de saúde suplementar é composto por 36,9 milhões de beneficiários de planos de saúde em 2006 representando 19,6% da população brasileira. Apesar do seu tamanho e da relação público-privada que permitiu seu desenvolvimento ao longo do século passado ocorreu à margem de um regramento oficial até 1998, com a promulgação das Leis 9.656/98 e 9.961/00, esta última criando a ANS, estendendo o processo de reconfiguração do papel do Estado para o setor de saúde. Entre 01/2000 e 12/2006 a ANS realizou 25 consultas públicas (4,2 consultas ao ano em média), destas 11 trataram de temas financeiros; enquanto questões cadastrais, de definição de produtos e de contratualização foram temas de três consultas cada. Neste mesmo período a ANS emitiu 790 normativos, uma média de 113 normativos por ano. A comparação entre consultas públicas e normativos sugere uma pequena participação externa à agência no processo de regulação. Desde sua criação em 1998 até 09/2006 a CSS se reuniu 44 vezes, considerando presença relativa (ponderada pelo número de convocações) as representações mais presentes foram: prestadores de serviço, medicinas de grupo, seguradoras, reguladores (ANS) e consumidores com 100%. No pólo inverso foram identificados: trabalhadores, governo e gestores com menos de 55% de presença relativa, sugerindo o grau de importância que cada grupo de representação confere à CSS, seja como fórum de debate ou espaço para disseminação de suas posições. Nestas reuniões foram pautados 129 temas, com predominância daqueles ligados a característica e estrutura da regulamentação (35% dos temas), apresentações da ANS (13% das pautas) e programas da ANS (9% dos temas). Temas como a avaliação da ANS pelos atores e discussão quanto a lacunas no processo de regulação, embora pareçam cruciais para a adequação do modelo, foram tratados apenas uma vez cada. Adicionalmente, a elaboração por parte dos atores da CSS de documentos para discussão foi tema em apenas duas das 129 pautas. As entrevistas com os atores da CSS revelam que há consenso quanto a Reforma do Estado ser a origem da regulação via agência, porém discute-se sua autonomia, distanciamento do controle social do SUS, falta de integração com políticas do Ministério da Saúde, interfaces entre os sistemas público e privado, renúncia fiscal, subordinação entre SUS e sistema suplementar, efetividade dos contratos préregulação e participação (ou interferência) do Judiciário no processo. A maioria das xv representações discute saúde suplementar desde o inicio dos anos 90, sofrendo o desgaste em função do longo período de participação e dos resultados aquém dos esperados. A composição heterogênea, não paritária e o caráter consultivo da CSS dificulta a construção do entendimento. A baixa participação de governo, trabalhadores e gestores e a discussão prévia entre ANS e MS dos assuntos relevantes corroboram com a avaliação de baixa produtividade dada à CSS. Há consenso pela busca de sustentabilidade do mercado, mas com divergências quanto às alternativas para atingi-la, com posicionamentos antagônicos quanto a incentivos fiscais, ressarcimento ao SUS, volume de lucro aceitável e metodologia de apuração dos reajustes de preços. Os gargalos apontados pelos atores foram sistemas e recursos humanos, falta de integração entre as diretorias da agência e o volume de normativos, que são apontados como fatores de lentidão e incremento de custos no processo regulatório. Ressaltam ainda a necessidade de maior participação da sociedade e transparência. São reconhecidos poucos sucessos (definição de produtos, direitos e cobertura, saneamento do mercado e programas de qualificação e troca de informação) e diversas lacunas (adequação do marco regulatório, integração interna da ANS, incorporação do prestador de serviços no campo regulado e integração com o SUS). Conclui-se que a regulação em saúde suplementar atingiu uma fase em que nenhum ator está satisfeito, mesmo entendendo ser este um processo em construção e dadas as divergências de interesses e limitações do fórum de discussão, a construção de consensos via CSS é complexa podendo não ocorrer. Adicionalmente, os posicionamentos e lacunas da agência no processo não permitem enxergá-la como efetiva defensora do interesse público em saúde suplementar. / This qualitative research is composed by a bibliographical analysis focused on state reform and regulation, the market structure analysis, the Câmara de Saúde Suplementar (CSS) meeting minutes analysis and by semi-structured interviews with CSS actors understanding positioning, discussion points, identifying successes and lacking points of the process. The objectives of this thesis are build a frame of reference for the supplementary health market, through a statistical analysis including analysis of the CSS meeting minutes, of the public consultations and rules issued by ANS; as well as analyzing the impacts of regulation on the several groups of interest represented in the CSS, discussing amplitude and range of regulation and questioning ANS mission achievement, as public interest defender in this market. The Brazilian supplementary health market assists 36.9 million beneficiaries, according to 2006 s data, which represents 19.6% of the population. Despite its size and the public-private relationship which allowed its growth since the beginning of last century, it remained unregulated until 1998. Regulatory activity was undertaken by ANS in 2000, extending State role reconfiguration concept to health field. Between 01/2000 and 12/2006 ANS called 25 public consultations (4.2 per year), from which 11 dealt with financial subjects, while masterfile, product definitions and contractualization were subject of 3 consultations each. During this period ANS issued 790 rules, an average of 113 per year. The comparison between the number of public consultations and of rules issued suggests small external participation. Since its creation in 1998 until 09/2006, CSS held 44 meetings. Considering relative participation, the most present representations were service providers, health maintenance groups, insurers, regulators and consumers with 100% of presence. On the other hand health workers, government and public health managers were present to less than 55% of the meetings, suggesting the relative importance given to CSS by each representation. During these meetings 129 different subjects were discussed. Main topics covered were regulation characteristics and structure (35%), ANS presentations (13%) e ANS programs (9%). Subjects as ANS evaluation and lacking points discussion, despite seeming crucial were dealt only once each. Additionally discussion of documents prepared by CSS actors took place only twice. Interviews seeked for actor s positioning on regulation model, were consensus resides on agency origin from state reform process, but autonomy, distance from SUS social control, lack of integration with Health Ministry policies, public and private systems interfaces, tax relieves, subordination of private system to SUS, effectiveness of preregulation contracts and Justice interference in the process are still points of discussion. The majority of representants have being discussing private health issues since the beginning of the 90s, suffering from the stress of long participation with limited results. The uneven composition and consulting status of the CSS are obstacles towards build understanding. Government s, health workers and public health managers low participation in CSS and pre-meeting discussions of relevant xvii subjects between ANS and MS, induce to a low productivity appraisal of CSS. Pursue sustainability seems to be a consensus, although ways to achieve this are discrepant, varying from definition of new fiscal incentives and reimbursement to SUS policy to definition of admited profit margins. ANS s evaluation by actors indicate botlenecks in IT and human resources, lack of integration within the agency s directorships and the amount of rules issued all of with contribute to increase costs and delay the regulatory process. Transparency and participation on decision processes are also claimed for. Few success examples are identified (product, rights and coverage definition, market clearing and implementation of quality programs) and several lacking points are indicated (adequacy of the regulatory base, internal integration, inclusion of the service providers in the regulated field and integration with SUS). Conclusions indicate that regulation has achieved a stage were none of the actors are satisfied, even recognizing that this is still a process in construction, and given the interest discrepancies between actors and limitations of the discussion arena, build consensus via CSS is complex and may not happen. At the same time, the number of lacking points in the regulation process show the distance for ANS to achieve its mission, and therefore do not allow see ANS as effective public interest defender in this market.