ABARÉ: a luta não terminou
22 de abril de 2013 por Caetano Scannavino
TAPAJÓS, REFERÊNCIA NACIONAL DA SAÚDE RIBEIRINHA: PORQUE NÃO?
Em apoio à “Carta dos Ribeirinhos sobre a Saúde nos Rios”, das organizações comunitárias do Tapajós, Arapiuns e Amazonas
Caetano Scannavino – Projeto Saúde e Alegria (PSA)
“O Navio-hospital Abare estava em vias de ser adquirido em definitivo pelo Ministerio da Saude e repassado a Santarem, quando mudou o Governo. Em 2013, talvez por desconhecimento, a atual gestão municipal fechou acordo de aluguel com os holandeses da TDH, donos do barco, para utilizá-lo somente 10 dias por mês, período abaixo do mínimo exigido por lei (24 dias-campo/mês), além de excluir Belterra e Aveiro dos atendimentos. Com isto, fere a Portaria Ministerial do Tapajos, e pode perder as verbas federais para suas operações – cerca de R$ 600 mil anuais. Se mantida a atual situação, corremos o risco de ver dezenas de barcos de saúde operantes pela Amazônia, exceto onde tudo começou.”
Desde que o modelo bem sucedido de atenção básica por meio do Navio-Hospital Abaré I – implantado em 2006 pelo PSA com as Prefeituras e apoio da TDH – foi reconhecido como política publica nacional, o polo Tapajós se tornou referencia em boas práticas de saúde ribeirinha.
Boa notícia para região, comunidades e municípios no enfrentamento do difícil desafio assistencial nas zonas rurais amazônicas, com dimensões do tamanho de países, grandes distancias, populações dispersas, e custos logísticos superiores aos padrões nacionais oferecidos pelo SUS.
Inspirado na experiência do Abaré I, o Ministério da Saúde (MS) lançou a política de Saúde da Família Fluvial por meio da Portaria 2.191 de 03 de agosto de 2010, aprimorada no ano seguinte através da Portaria 2.488 de 21 de outubro de 2011. Ela aprova a nova Politica Nacional de Atenção Básica, novos arranjos de Equipes de Saúde da Família (ESF) – ESF Ribeirinha e Fluvial – além de critérios para implantação e financiamento de barcos de atendimento às populações remotas com vistas a apoiar os municípios de toda Amazônia Legal e Pantanal, sua área de abrangência. Uma grande conquista, pois permitiu disseminar o que se semeou no Tapajós para outras regiões necessitadas.
Atualmente, mais de 50 novas embarcações assistenciais vem sendo implantadas e custeadas com apoio financeiro federal. O primeiro deles foi o próprio Abaré I, que em dezembro de 2010 foi credenciado pelo Ministério como a primeira Unidade Básica de Saúde (UBS) Fluvial do país, sendo integrado ao SUS. A partir daí, os Municípios envolvidos assumiram a sua gestão, liderada por Santarém, que passou a receber desembolsos mensais de R$ 50 mil (R$ 600 mil/ano) – conforme padrão previsto na Portaria por embarcação – para uso exclusivo nas rodadas assistenciais que incluem também Belterra e Aveiro, dando continuidade aos atendimentos para mais de 15 mil ribeirinhos das duas margens do Tapajós.
Desde então, há mais de dois anos, apesar do PSA ter deixado a linha de frente das operações, continuou apoiando as comunidades no controle social, na educação/prevenção em saúde, assim como a gestão pública quando solicitado.
Um marco histórico foi a campanha pela permanência do Abaré I no inicio do ano passado, diante da ameaça de retirada da embarcação pela organização holandesa Terre Des Hommes (TDH), sua proprietária.
O desdobramento desta campanha, após intensos embates, inclusive pelas vias judiciais, tomou rumo por uma solução definitiva a partir de uma reunião na Holanda (abril/12) entre representantes da Prefeitura e da TDH. Negociações foram iniciadas com o aval do Ministério da Saúde para a compra do Abaré I – em torno de 600 mil euros ou aproximadamente R$ 1,5 milhão – com recursos federais assegurados não apenas para aquisição, como também para sua manutenção complementar, que por se tratar de uma embarcação de grande porte, tem um custeio superior as dotações orçamentárias da Portaria Ministerial.
Para aquisição do Abaré I pelo Ministério e o seu repasse a SEMSA/Stm (clique aqui para ver os documentos oficiais), alguns processos burocráticos obrigatórios foram iniciados – arranjos jurídicos, perícias técnicas da Marinha para avaliação e precificação da embarcação, etc. No entanto, mais uma vez a TDH mudou de forma abrupta sua posição, quando em dezembro passado notificou a Prefeitura de que não queria mais vender o barco, isto após meses de encaminhamentos.
Diante disso, a SEMSA solicitou a desapropriação do Abaré I ao Ministério, que no apagar das luzes de 2012, se manifestou favoravelmente, já que infelizmente esta era a única opção. Com a mudança do Governo Municipal, todos estes processos em curso foram paralisados, pois dependiam de deferimento da nova gestão para seguirem adiante.
Já em 2013, talvez por falta de conhecimento dos encaminhamentos antecedentes, a SEMSA/Stm fechou acordo de aluguel do Abaré I com a TDH, passando a pagar a organização holandesa pela disponibilidade da embarcação por apenas 10 dias mensais.
Infelizmente, além da suspensão do processo de compra do Abaré I, este acordo de aluguel bate de frente com as condicionantes da Portaria Ministerial no Tapajós, seja pela exclusão de Belterra e Aveiro, seja por ser um período inferior de dias em campo ao mínimo obrigatório exigido por lei (de 24 dias/mês), o que acarretará a interrupção dos repasses federais mensais de R$ 50 mil, se não resolvido com urgência.
Resumindo: Santarém, além de estar pagando pelo aluguel do Abaré I, deixará de receber as verbas do Ministério da Saúde, quando poderia ser proprietário da embarcação com recursos para sua manutenção custeados pelo Governo Federal. Se mantida a atual situação, corremos o risco de ver dezenas de barcos de saúde operantes pela Amazonia, exceto onde tudo começou.
Perspectivas
Apesar do todo ocorrido em torno da Novela Abaré, o cenário nunca esteve tão favorável para Santarém como agora. Além de ainda se manterem abertas as perspectivas de aquisição do Abaré I para perpetuação dos serviços no Tapajós, já se encontra em condições de operação o Abaré II, adquirido pelo PSA e repassado via comodato à Prefeitura para atender a região do Arapiuns. Isto sem falar na aprovação de mais R$ 1,2 milhão para a SEMSA construir e equipar uma terceira embarcação planejada para assistência na bacia do Amazonas.
Se somadas as verbas federais de investimento (aquisição do Abaré I e construção/equipagem de uma terceira embarcação) e custeio para três Unidades Fluviais (manutenção, combustíveis, tripulantes, equipe de saúde, etc…), tratamos aí de valores da ordem de R$ 11 MILHÕES – isto contabilizando apenas os próximos 4 anos – destinados pelo Ministério à Prefeitura de Santarém para apoiar a saúde dos ribeirinhos de nossa região.
Cabe lembrar que a aquisição definitiva do Abaré I abre um enorme potencial para diversificação dos serviços, incorporação de novos parceiros e programas, incrementando o papel social da embarcação. Dotado de instalações mais amplas do que o padrão das demais Unidades de atendimento, poderá também funcionar como Barco-Escola – com o envolvimento de Universidades como a UEPA, USP, etc – um indutor para interiorização da medicina na Amazônia, na forma de um laboratório e polo difusor de boas praticas que possam ser replicadas para as outras regiões contempladas pela Portaria 2.488/2011, entre outras benesses que justificam o interesse do Ministério da Saúde, conforme as negociações que vinham avançando até o final do ano passado.
Enfim, oportunidades estas conquistadas cujos encaminhamentos e processos decisórios cabem exclusivamente aos atuais entes públicos, assim como os recursos financeiros, destinados apenas para uso governamental. Mas não podíamos deixar de citá-las, mesmo porque dizem respeito a saúde de uma população na qual dedicamos quase três décadas do nosso trabalho frente a construção de um modelo de atenção básica exitoso, resoluto, sustentado e adequado ao contexto amazônico.
Não dispomos de detalhes para saber se a saúde ribeirinha foi devidamente pautada pelos governos de transição, mas é inegável que o momento de tramitação burocrática de todos estes processos não foi o ideal, entre final e início de novas gestões.
Isto gerou morosidade nos procedimentos junto ao Ministério da Saúde ao final do mandato passado, de certa forma atropelados pela agenda das campanhas eleitorais: seja o diálogo intermunicipal em função da área de abrangência do Abaré I envolver Santarém, Belterra e Aveiro; seja o processo de compra do mesmo, dando margens à novas “voltas atrás” da instável TDH; seja o credenciamento do Abaré II como UBS Fluvial para Santarém começar as receber os repasses mensais de R$ 50 mil previstos na Portaria também para esta Unidade; seja para agilizar as pendencias e iniciar a construção da terceira embarcação.
E já sob a nova gestão, houve precipitação no tocante à formalização de acordos sem antes se municiar das informações relativas às oportunidades e legislações vigentes, como por exemplo, o acerto da SEMSA/Stm no inicio deste ano para pagamento de aluguel do Abaré I à TDH.
Mesmo compreendendo as dificuldades nos processos de mudança de governos, se analisarmos o conjunto da obra, no caso da saúde dos rios, a herança é mais do que bendita. O importante é que o Ministério da Saúde mantém em 2013 ainda aberta esta janela de oportunidades, embora não saibamos por quanto tempo, mas que se for conduzida com agilidade pelos atuais gestores, pode sacramentar nossa região como o polo difusor de saúde ribeirinha do país.
É pegar ou (não) largar!
Leia também a Carta dos Ribeirinhos sobre a Saúde nos Rios e os documentos oficiais do Ministério da Saúde à Secretária Municipal de Saúde de Santarém – SEMSA sobre a compra do Abaré I no link a seguir: Cartas MS – SEMSA
Conheça mais sobre a questão clicando aqui.
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