A Política Nacional de Atenção Especializada em Saúde (PNAES) e seus impactos no SUS: uma análise à luz do modelo de múltiplos fluxos

Abstract

INTRODUCTION: The National Policy for Specialized Health Care (PNAES), established in 2023, represents a structural milestone in the Brazilian Unified Health System (SUS), integrating systemic, organizational, and professional dimensions to address the challenges of specialized care. With a focus on equity, comprehensiveness, and regionalization, it is composed of a complex structure of three dimensions (systemic, organizational, and professional) and nine structural elements. The PNAES is based on: improving a care model aligned with users’ needs, prioritizing and simplifying access to Primary Health Care (PHC) as the gateway and coordinator of care; the adoption of new payment models; the implementation of digital health; territorialization and regionalization, strengthening relationships with complementary networks, and training and providing specialists. The policy also aims to promote continuing education. This study analyzes the structure of the PNAES, its guidelines and foundations, and discusses its developments in light of John Kingdon’s Multiple Streams Framework. OBJECTIVES: To analyze the formulation and impacts of the PNAES within the SUS, based on the Multiple Streams Framework, highlighting its guidelines and comparing it with Latin American policies. METHOD: This study is characterized as a qualitative, descriptive, and exploratory analysis, based on documentary research and public policy analysis. The investigation focused on the PNAES, established by Ordinance GM/MS No. 1,604/2023, and was conducted using John Kingdon’s Multiple Streams Framework, aiming to understand the determinants and processes involved in its formulation and implementation. Initially, a review of official regulatory documents, institutional reports, technical-scientific literature, and publications on the structuring of specialized health care was carried out. Subsequently, the analysis was organized into three central streams, as proposed by Kingdon: the problem stream, the policy stream, and the politics stream, which allowed the identification of critical elements that led to the opening of a “window of opportunity” for policy formulation. In addition, a comparative analysis was conducted between the PNAES and similar policies in Latin American and Caribbean countries, with emphasis on Argentina, Chile, Colombia, and Peru. This stage aimed to contextualize the Brazilian experience within the regional scenario, identifying points of convergence and divergence regarding financing, organization of specialized care, incorporation of health technologies, and articulation with Primary Care. The triangulation between the theoretical framework, institutional documents, and comparative data allowed a deeper understanding of the structuring role of the PNAES within the SUS, as well as the tensions, advances, and challenges inherent to its implementation. RESULTS: The analysis showed that the formulation of the PNAES was driven by a scenario of normative disarticulation, fragmentation of specialized care, and progressive underfunding of the sector, configuring an accumulation of long-standing unresolved demands within the SUS. The application of Kingdon’s Multiple Streams Framework demonstrated the convergence of three central vectors: the emergence of structural problems related to specialized care; the availability of technical and institutional solutions previously discussed by experts and managers; and a favorable political environment for health policy restructuring following the change in the federal government. The problem stream was characterized by the identification of care bottlenecks, such as long waiting lists, low resolvability of specialized services, lack of effective access regulation mechanisms, and insufficient federal funding. The policy stream pointed to proposals formulated by technical groups within the Ministry of Health (MS), state and municipal health secretaries’ councils, and civil society organizations, emphasizing the need for integration between levels of care, regionalization of service provision, and strengthening of federative governance. The politics stream, in turn, was driven by the reestablishment of the Ministry of Health’s coordinating role within the SUS, social mobilization in defense of the system, and the prioritization of health in the 2023 governmental agenda. The synchronization of these three streams resulted in the opening of a “window of opportunity” that enabled the formulation and publication of the PNAES as a structural policy. DISCUSSION AND CONCLUSIONS: The PNAES represents a strategic milestone in the reconfiguration of specialized care within the SUS, integrating guidelines that promote equity, regionalization, and continuity of care. Its formulation, analyzed through the Multiple Streams Framework, highlights the importance of articulation between technical diagnosis, participatory formulation, and a favorable political context. The policy addresses historical challenges in the sector, such as fragmentation of the care network and mismatch between supply and demand, proposing solutions grounded in evidence and intergovernmental strengthening. Integration with Primary Care and the use of digital technologies stand out as structural innovations. In the Latin American context, the PNAES positions Brazil as a regional reference by institutionalizing a robust national policy for specialized care. However, its effectiveness will depend on implementation capacity across territories and on sustained commitment to evaluation and continuing education.