Intergovernmental health policy decisions in Brazil: cooperation strategies for political mediation.

The advantages of established intergovernmental decision-making arenas for the implementation of health policies in decentralized settings are not well known. This paper presents the case of the joint health management committee, known as the Tripartite Committee, created to formalize intergovernmental decisions about the implementation of policies of the Brazilian Unified Health System. This paper adopts a descriptive approach for the strategic analysis of decision process among governmental actors from three federative levels, as well as of mechanisms for the negotiation of their interests in the formalization of health policy agreements. The roles and positions of governmental actors within the Tripartite Committee were analysed, together with the definition of decision agendas and strategies. The data come from normative documents and proceedings of the Tripartite Committee, interviews with their governmental actors and observations of their meetings. The distinct governmental actors from the Tripartite Committee employed cooperation strategies with permanent negotiations oriented towards interchanges and political mediation. The power of the federal Government is also pre-eminent for the constitution of decision agendas and in the shaping of negotiation processes and priorities. The Tripartite Committee formalized agreements between unequal administrative and political powers to ensure a systemic integration of governmental policies and a self-regulation of the political autonomies. There are some divergences within the governmental actors' interpretation of key policies and processes in this decision arena; the primacy of political or technical criteria as well as the applicability of laws or ad hoc norms. Although such cooperation strategies may slow down the decision-making process and render it more complicated, they also define more clearly areas of institutional responsibility and ensure a broader support from different levels of government for the implementation of public health policies.