Paloma Carpena de Assis

This thesis covered the topic of organ supply and donation (particularly kidneys) and was organized into three essays. The first one analyzed the organizational structure of the renal transplant system in Brazil, from the New Institutional Economics theoretical approach. Since its creation in 1997 until 2017, it was found that the aforementioned system developed a governance structure, which originated from the transformation and learning that occurred over time. These changes came about as a result of the interaction between State and society, but generated incomplete contracts and therefore, market failures (limited rationality, asymmetric information and transaction costs). The kidney was classified as a highly specific asset and the institutional environment of said system presented a hybrid governance structure (cooperation agreements between government and transplant teams) until 2017. After the Federal Decree # 9.175, stablished that same year, there was the conclusion that this structure started to display hierarchical characteristics (decisions at the national level, with coordination and imposition of a centralized authority). The theoretical analysis indicated the following results: i) reduction of transaction costs by coordinating the decision-making between the economic agents involved; ii) structural changes in governance as well as institutional changes; iii) performance improvement of the system, seeking dynamic and static efficiency and; iv) better local coordination (at national, state and municipal levels) between the government, Health Care professionals, patients and society as a whole. The second essay of this thesis analyzed spatial factors associated to the kidney transplant rate among Brazilian federative units, between 2012 and 2017. The methodology employed was Exploratory Spatial Data Analysis and the econometric Spatial Data Panel model. The explanatory factors were grouped into sociodemographic (schooling, population density and population aging rate), management (effective donors rate and kidney transplant team rate) and infrastructure (Intensive Care Unit - ICU beds rate) of the national transplant system. An unequal distribution of this type of transplant was found among these areas over the analyzed period, with concentrations in the South and Southeast regions of the country (High-High type clusters). Education and population aging rate had positive effects (global and local) on the kidney transplant rate. Population density was negatively related to this rate. Regarding effective donors rates and kidney transplant teams, the association with the transplant rate was also positive. The ICU beds rate had a negative effect of neighboring federative units on the behavior of the dependent variable in the unit of analysis (spatial spillover). Aiming to analyze the spatial factors associated to the effective organ donation rate amongst Brazil’s federative units, between 2012 and 2017, organ and tissue donation-transplant economy and spatial econometrics were used as theoretical tools (Exploratory Analysis of Spatial Data and Spatial Data Panel model). The conditioning factors used were organized as follows: i) sociodemographic (schooling - IDHM Education -, population density and population aging rate) and ii) national system management (emergency ventilators or respirators rate, mortality rates from neurological causes and dummies related to public policies that created the Organ Procurement Organizations – OPO’s and the Intra- Hospital Commissions for Organ and Tissue Donation for Transplantation – IHCOTDT’s). It was made evident the great regional disparity in the process of donation-transplantation between those areas, with spatial groupings of the High-High type in the Southern region of the country. Education and population density had positive effects on the organ donation rate. The population aging rate, on the other hand, had negative indirect and total results on this rate. The emergency respirators-ventilator rate impacted the growth of the donation rate in the analyzed areas. The mortality rate from neurological causes in the neighboring federative units affected these donations negatively in the analyzed unit and had a positive local effect. Dummy variables for OPO's and IHCOTDT's had positive effects, indicating their importance for this process. Therefore, the conclusion was that an institutional environment with an adequate governance structure and public policies of demand and awareness to organ donation contribute to the growth of the kidney transplant rate (national and local scope). Effective decisions (based on evidence) made by those managing the system are necessary in order to improve the structural and dynamic performance of the donation-transplant process, particularly in relation to regional differences in the supply of organs in the country.