Challenges of implementation of the QualiSUS-Rede project in BrazilAbstract
Background: There is a lack of analyses on the implementation of projects funded by the International Bank for Reconstruction and Development (IBRD) in a broader perspective.
Objective: Analyze the perception of the players involved in implementing the Health Care Network Formation and Quality Improvement Project (QualiSUS-Rede) project in order to identify the barriers and facilitators they faced in establishing health care networks.
Methods: Qualitative study based on 191 semi-structured interviews with individuals involved in implementing QualiSUS-Rede at the municipal, state and federal levels, covering 15 regional subprojects. The Interface de R pour les Analyses Multidimensionnelles de Textes et de Questionnaires (IRaMuTeq) software was used to analyze the interviews. The Descending Hierarchical Classification was adopted.
Results: Textual use was 99.27%. The interviews converged around two main discursive classes and seven subclasses. The following facilitators were identified: motivation to implement QualiSUS-Rede; participatory management; and promotion of discussions about health care networks. The barriers were predominantly related to aspects external to QualiSUS-Rede, such as excessive bureaucracy, low administrative capacity, and absence of knowledge about World Bank guidelines.
Conclusion: The QualiSUS-Rede project contributed to strengthening local governance and regional planning. However, barriers emerged from several aspects, such as failure in prioritizing investments, opting for ambitious objectives to be achieved in a very short timeframe, and low local capacity to deal with bureaucratic and administrative obstacles.
Keywords:
health systems; regional health planning; delivery of health care; primary health care
Resumo
Introdução: Faltam análises sobre a implementação de projetos financiados pelo Banco Internacional para Reconstrução e Desenvolvimento (BIRD) em perspectiva ampliada.
Objetivo: Analisar a percepção dos atores envolvidos na implantação do projeto QualiSUS-Rede, a fim de identificar as barreiras e facilitadores enfrentados na constituição de redes de atenção à saúde.
Métodos: Estudo qualitativo baseado em 191 entrevistas semiestruturadas com os atores envolvidos na implementação do Projeto de Formação e Melhoria da Qualidade da Rede de Atenção à Saúde (QualiSUS-Rede) nos níveis municipal, estadual e federal, abrangendo os 15 subprojetos regionais. O software Interface de R pour les Analyses Multidimensionnelles de Textes et de Questionnaires (IRaMuTeq) foi utilizado para analisar as entrevistas. Adotou-se a Classificação Hierárquica Descendente. Os resultados foram divididos em classes e subclasses.
Resultados: As entrevistas convergiram em torno de duas classes discursivas principais e sete subclasses. Foram identificados os seguintes facilitadores: motivação para a implantação do QualiSUS-Rede; gestão participativa; indução de discussões sobre as redes de atenção à saúde. As barreiras estiveram predominantemente relacionadas a aspectos externos ao QualiSUS-Rede, como excesso de burocracia, baixa capacidade administrativa e desconhecimento das diretrizes do Banco Mundial.
Conclusão: O projeto QualiSUS-Rede contribuiu para fortalecer a governança local e o planejamento regional. No entanto, constituíram-se como barreiras a falha na priorização de investimentos, a opção por objetivos ambiciosos a serem alcançados em um prazo muito curto e a baixa capacidade local para lidar com entraves burocráticos e administrativos.
Palavras-chave:
sistemas de saúde; regionalização da saúde; atenção à saúde; atenção primária à saúde
BACKGROUND
With the ever-increasing expenditures on health, the search for efficiency is essential to sustain health care systems worldwide1. Achieving more with fewer resources has been a challenge for health administrators2,3. The use of health technology assessment has increased significantly worldwide4, but analyses generally focus on individual technologies, such as medication, equipment and medical devices5. However, to obtain better health results, it is important to evaluate how health services are structured and integrated to provide care. Regionalizing health services has been suggested as a promising strategy to enhance health processes and results6,7. Regionalization is defined as the rational distribution of services in a territory, guaranteeing timely access and quality to three levels of health care (primary, secondary and tertiary)6.
In this context, services with less advanced technology, such as primary care, should be spread out and located near the residence or workplace of individuals; services with more complex technology, such as hospitals, clinical pathology laboratory services, and imaging equipment, should be concentrated11.
Although health care networks stem from the Dawson Report of 1920, they were implemented relatively recently, and were introduced in the USA in the 1990s based on the experiences of integrated health systems12.
The idea of regional health care networks (RAS) was included in the 1988 Federal Constitution, but only regulated in 2010 by Ministerial Decree GM 4.27910, a result of the first consensus involving the three branches of government. RAS are polyarchic organizations of health services, interconnected by a single mission, common goals and cooperative and interdependent action, aiming to offer continuous and comprehensive care to a given population9. The operational structure of RAS consists of five components: the communication center, primary health care; secondary and tertiary care points; support systems; logistical systems; and the health care network governance system9.
A study carried out in Brazil, Chile, Colombia, Mexico and Uruguay that analyzed RAS to improving clinical coordination for different levels of the health system revealed that the implementation process requires time and institutional support, long-term evaluation and funding13.
Since then, a number of health care network support initiatives have been implemented by the federal government. One of these was the Health Care Network Formation and Quality Improvement Project (QualiSUS-Rede), formalized by the 2009 Loan Agreement between the Ministry of Health and International Bank for Reconstruction and Development (IBRD), with a global value of US$ 235 million14.
QualiSUS-Rede was structured into three components; the first aimed at qualifying the care and organization of RAS, for which the largest portion of the funding was allocated, totaling US$ 205 million (87% of the total). The second component was related to systematic strategic interventions to strengthen logistics in the health region, and the third component was reserved for QualiSUS-Rede management (planning, implementation and execution). It was operationalized by a complex shared management design, as can be seen in Figure 1.
Health Care Network Formation and Quality Improvement Project (QualiSUS-Rede) — organization and functioning
QualiSUS-Rede: Health Care Network Formation and Quality Improvement Project.
Implementing QualiSUS-Rede involved a wide range of players, including an international entity; national, state and municipal governments; and, in some cases, universities and social control groups. The regions established under QualiSUS-Rede were highly diverse in terms of socioeconomic conditions and health infrastructure, which required the implementation of different governance arrangements. Governance is strategic to the functioning of RAS, since it is an institutional and organizational arrangement that may enhance the management of all the structural components of the network. Moreover, one of its functions is to strengthen cooperation and solidarity among its members15.
The overall assessment of the IBRD regarding QualiSUS-Rede was classified as moderately unsatisfactory16. However, the literature reports positive aspects, especially with respect to coordination between municipal and state governments, in addition to personnel training and qualification prior to implementing the proposed networks17. The project also contributed to formalizing agreements among municipal governments via Regional Inter-Management Commissions (CIR), with participants recognizing QualiSUS-Rede as an important instrument to strengthen governance in the regions18. However, these articles give a partial view of the QualiSUS-Rede implementation. One study investigated just three out of 15 regional subprojects (from the North of Brazil only)16. The other study only included the perception of local supporters, not considering other relevant players such as municipal, state and federal health managers, who have the responsibility of prioritizing actions and giving political and financial support18. Moreover, there is a lack of analyses on the implementation of projects funded by the IBRD in a broader perspective, taking into consideration aspects other than allocative efficiency19, such as local political and organizational arrangements.
In this respect, it is important to understand the perception of those involved (all players) in implementing QualiSUS-Rede in Brazil (all regional subprojects), in order to identify the barriers and facilitators of the process. This evidence may contribute to improving other health care network implementation projects in future undertakings funded by the IBRD and other financing sources, particularly in low and middle-income countries.
The aim of this study was to analyze the perception of the players involved in implementing the QualiSUS-Rede project in order to identify the barriers and facilitators they faced in establishing RAS, specially aiming to understand which factors contributed to hamper the implementation of the project financed by the International Bank for Reconstruction and Development (IBRD).
METHODS
Design
This is an exploratory descriptive case study with qualitative data. Case studies are considered suitable strategies to explain how or why a certain intervention was applied; when the researcher has little or no control over the context; and when a contemporary phenomenon is investigated in a real context20.
A total of 15 regional subprojects were funded in 17 states (two subprojects were used in more than one state), ten in metropolitan regions and five in regions denominated “Type” because of their regional peculiarities. These subprojects were, per region of the country: the metropolitan region of Rio de Janeiro, Belo Horizonte, Curitiba and ABC in the Southeast; Florianópolis and Porto Alegre in the South; the metropolitan region of Recife, Teresina, Agricultural Border Juazeiro/Petrolina — PEBA and the Semiarid Region of Cariri in the Northeast; the Integrated Region of the Federal District an Surroundings (RIDE), Federal District, Minas Gerais and Goiás, the Internal Border Region of Ponta Porã/MS in the Center-West; and the Alto Solimões Region —Indigenous population, Interstate Region Bico do Papagaio (TOPAMA) in the North. Each region prepared a subproject, prioritizing investments in the following areas: basic care, thematic networks, logistical support, therapeutic and diagnostic support and regional governance14. For more details on the 15 regional subprojects, see Table 1.
Sample and data collection
The sample consisted of 191 semi-structured interviews, conducted between July and December 2014. The inclusion criteria were the professionals’ experience with the project. Two participants refused to record the interviews. The semi-structured interviews were carried out by research assistants who were trained in advance, and took place in every region. Interviews with individuals directly responsible for implementing QualiSUS-Rede were considered eligible. The questions reflected issues related to regionalization, RAS and how the QualiSUS-Rede project contributed to improve them. Questions also asked participants on barriers and facilitators in implementing regional RAS. At the municipal and state levels, the respondents were members of the 15 working groups established to execute the regional subprojects. These groups consist of municipal departments, representatives of state health departments, municipal health councils (COSEMS) and institutional supporters of the Ministry of Health who live in the regions and, in some cases, representatives of universities and municipal health councils (social control) were also included. At the federal level, interviews were conducted with QualiSUS-Rede Project Management Unit (UGP) managers, representatives of the Ministry of Health and the National Council of Health Departments (CONASSS), which belong to the QualiSUS-Rede General Implementation Committee (CGI), and one IBRD representative, as the financial agent of the project.
In terms of general description of participants, 112 (65.5%) were female, the mean age was 45 years (±10.64), 184 (96.8%) had completed an undergraduate degree, and 130 (68%) were civil servants.
Data analysis
We used the Interface de R pour les Analyses Multidimensionnelles de Textes et de Questionnaires (IRaMuTeQ) version 0.7, developed by Pierre Ratinaud21, to identify the main speech patterns, as well as ways of speaking and reflecting about the topics of interest, enhancing the transparency and objectivity of data analysis. After running the corpus through IRaMuTeQ, a thematic analysis of the case notes was conducted.
This free software is anchored to R software and Python programming language, and was introduced in Brazil in 2013, primarily in the health area22. IRaMuTeQ can perform five types of textual data analysis: classic textual statistics; group specificity research; similitude analysis; word cloud; and descending hierarchical classification (DHC). These techniques make it possible to identify the rapport or corpus, the text segments (TSs) formed, and active, supplementary and hapax words (words that appear once in the corpus)23,24.
Textual data analyses included everything from simple analyses, such as the basic lexicography obtained by calculating word frequency, to multivariate analyses that produce DHC22,25. Data processing produces the TS classes contained in similar vocabulary and different vocabulary from the other segment classes. Next, the processed data are organized and presented as figures that illustrate the relationships between the classes24,26. In social studies, these classes may indicate social representations or image fields on a given object, or only aspects of the same social representation26. The interviews (texts) were randomly coded, and DHC was used. The figure that expresses data organization in DHC is the dendrogram.
Classes and sub-classes emerged from the DHC performed by IRaMuTeQ, taking into consideration pairs of words and sentences that are often statistically associated, gathering them into the same class of discourse; words that are less frequently associated form distinct classes. The association between vocabulary and classes is measured by χ2 tests.
The research project was approved by the Research Ethics Committee number 213.691/2013.
RESULTS
Corpus processing in IRaMuTeQ obtained a textual use of 99.27%. A total of 16,536 of the 16,685 TSs identified were classified, the number of times the corpus was divided. The number of active forms in relation to a frequency greater than or equal to 5 was 2,666.
Interpretive analysis of the corpus by DHC analysis using IRaMuTeQ, considering lexicometric characteristics, produced a dendrogram (Figure 2), which indicated the convergence of empirical characteristics around two main discursive classes and seven distinct subclasses, whose denominations resulted from analysis of word meanings and correlation with the TSs obtained.
Dendrogram representing the classes and subclasses resulting from Interface de R pour les Analyses Multidimensionnelles de Textes et de Questionnaires (IRaMuTeQ) analysis with descendent hierarchical classification (CHDDHC)
The first class, “Governance Arrangement of QualiSUS-Rede and Barriers and Facilitators to its implementation (Figure 1)”, with 44.53% of the corpus analyzed, contains subclasses 5, 6, 2 and 1, and discusses the positive expectations of the QualiSUS-Rede, bureaucratic and administrative obstacles, the participatory management model and the organizational and operational arrangement adopted, as well as the relationships established among federal, state and municipal levels and between these levels and the financing agent (IBRD).
Subclass 5, “Positive expectation of the QualiSUS-Rede”, demonstrates that the QualiSUSRede project was considered credible in the regions. It expresses the effort and desire of players in executing the project and achieving the objectives established in the working plans for regional projects. “[...] when preparing a project, everybody wants it to be very successful. We like to make things happen and get results”. The respondents perceived that the results could promote health improvements for people living in the territories.
Subclass 6, “Bureaucratic and administrative obstacles”, reports the difficulties in implementing the subprojects, particularly prolonged bureaucratic procedures such as tenders, which consist of numerous stages that hinder acquisition of the inputs needed to plan activities in a timely fashion. Bureaucracy and the demands established by states, the federal government and the IBRD were cited as barriers. The time period stipulated by the Loan Agreement for executing subprojects was considered “very short”. The inability of most states to meet purchasing demands was also mentioned.
First of all, IBRD has many demands in relation to tenders. Some processes require prior approval, and for others we didn’t have a supplier... Tender processes are very complicated. When we managed to conclude the tendering process, no companies were interested in participating.
Subclass 2, “Participatory management in the QualiSUS-Rede”, presents the management model adopted, which was broad-based and participatory, involving all decision-making levels (federal, state and municipal). The political and administrative operationalization of regional subprojects occurred by forming local working groups, officially instituted by the state health departments. They were composed of different players, including secretaries and directors of municipal and state health departments, local supporters representing the Ministry of Health, and, in some cases, representatives of organized civil society, with the participation of universities and social control groups. The interviewees showed the importance of articulating these players, especially the councils of municipal secretaries (COSEMS), which were strategic for local governance. This participatory arrangement contributes as a facilitating factor for the implementation of the subprojects, mainly due to large regional differences.
To consolidate the experience of state-municipality cooperation, the state university, COSEMS, state and Municipal Health Councils participated. COSEMS and the state council also participated.
Subclass 1, “Organizational and operational arrangement”, demonstrates the modus operandi of the QualiSUS-Rede project, using working groups whose initial function was to perform regional diagnoses of the health situation that aided the creation of regional subprojects, in addition to implementing and monitoring ongoing regional projects. The group met regularly (usually monthly). It was reported that the work was conducted in a participatory manner.
Preparation (of subprojects) was participatory. In addition to participating in all the meetings, we also try to read through the minutes. The group also communicates by telephone.
At these meetings, the regional subprojects were planned, presented and submitted to interagency committees, such as the Regional (CIR) or Bipartite (CIB) Interagency Commissions. The interview shows that decisions about priorities were made at the CIR, demonstrating that it is strategic space for governance. “The priority issues were established in CIR along with the state health department”.
The second class, “Health care networks in the context of QualiSUS-Rede”, with 55.47% of the corpus analyzed, contains subclasses 7, 3 and 4, with the discourse of the individuals interviewed regarding barriers to health services and the need to organize the health care network with a view to overcoming systemic fragmentation. It discusses the difficulty of organizing the network due to the absence of the tools required to guarantee comprehensive care, including therapeutic and logistical support systems and network governance, particularly in the North and Northeast of the country, where medium and high complexity services are scarce or non-existent.
Subclass 7, “Difficult access to health services”, discusses the perception of players regarding the low capacity of the system to meet patient demands for appointments, treatment and examinations in a timely fashion. They report an increasing demand for specialized hospital care as the entry point to the health system, which has significantly impacted municipal budgets, and argue that structuring hospital services involves more than just providing beds. One of interviewees mentioned the lack of services: “A major gap is the population’s access to the service. How many beds do I need? There is no use sending 100 pregnant women to your hospital if you can only accommodate 50”.
Also, lack of a regulation is an important problem, since patients are ultimately referred to hospitals that belong to the network within a particular health region, but on arriving at the unit, find the bed does not exist, meaning they have to search throughout the network.
Administrators linked to regional subprojects in the states of Tocantins, Pará and Maranhão, the region of Alto Solimões and municipality of Teresina, Piauí state, reported wide gaps in care and lack of access to specialized services, requiring users to seek treatment outside their health regions, thus having to travel substantial distances. The interviewee below reported the dilemma involved in the provision of oncology services.
“In oncology patients end up costing the system much more. The doctor prescribes a series of exams for a radiotherapy patient, who leaves the hospital with all these requests for tests, and then what…?
This means that municipalities with medium and high complexity structures are overloaded by the large number of patients from neighboring municipalities that do not offer these services. These municipalities feel “invaded” and allege not having sufficient resources for their own city, let alone to treat patients from other locations.
The low capacity of some regions is a limiting factor in organizing the networks. The project proposed funding the development of network integration and service coordination mechanisms. The question that the interviewees left unanswered was how to improve the network’s organization and develop coordination mechanisms when the operational structure is inadequate and has significant health care gaps.
Subclass 3, “Devices to create the care networks”, refers to the operational structure of the network, that is, the components funded by QualiSUS-Rede to support creating or strengthening the regional networks. Each subproject could select between one and five areas to invest in, provided they were in line with the initial situational diagnoses of each region. They reported investments in the logistical support system, especially patient transport in the subprojects of Cariri and Teresina, in the states of Ceará and Piauí, respectively; they recorded the implementation of the information system for basic care (e-SUS) and pharmaceutical care qualification (Hórus) in nearly all the municipalities enrolled in QualiSUS-Rede.
Logistical support, and the governance system of governance also progressed. In the logistics system, resources for qualification, acquisition of information technology equipment’. [...] funds to purchase eight obstetric ultrasound machines, to reinforce the cegonha network.
There was also investment in the therapeutic diagnosis system, governance system and primary care qualification, important devices in network organization and health system integration.
Subclass 4, “Implementation of health care networks”, discusses the context of including QualiSUS-Rede in primary care qualification, which is considered the coordinator of health systems, and thematic networks (mother-child, urgent and emergency care, psychosocial and chronic diseases), which are linked to resources aimed at structuring and funding contracted health services. “Each state is drawing up its action plans for the cegonha network, urgent and emergency care network, psychosocial network. This might not have been possible without QualiSUS”.
Some respondents felt that QualiSUS-Rede would strengthen the existing policy and add to previously institutionalized investments or those underway. They stated that the project promoted discussions on the regional network and made it possible to create management instruments, regional health plans and coordination with thematic networks. They also mentioned that the network had not proven to be very effective because administrators have a fragmented and poorly coordinated view of health care. Furthermore, although all the formal elements of the network are present, they do not function in practice, which limits its problem-solving capability. Another important aspect cited is that for RAS to function better, investment in human resource training is necessary, especially in primary care, which has yet to assume its coordinating role in the network.
As can be seen in Table 1, the metropolitan regions of Rio de Janeiro, Belo Horizonte and Recife gave up on executing the subprojects. It should be noted that, of the interventions performed, the infrastructure ones stand out: qualification of the infrastructure of specialized and hospital services (works and equipment), qualification of primary care infrastructure (works and equipment), and training of primary care teams, followed by the training of professionals for the stork network, the training of professionals for the Urgency and Emergency Network (RUE), and the strengthening of regional governance. However, it was observed that important interventions to advance the construction of care networks were little carried out in the subprojects.
DISCUSSION
In the present study, three main facilitators were identified. The first is related to the fact that QualiSUS-Rede is perceived by administrators as an opportunity to improve health services. The second is the selection of participatory management for all the QualiSUS-Rede implementation phases (situational diagnosis, planning and execution). This strengthened integration and the regional governance model, thereby complying with the Unified Health System (SUS) institutional framework, which considers municipalities as privileged spaces to overcome the challenges and dilemmas inherent in the Brazilian health system. As such, it is essential to construct a solid local governance framework, capable of providing technical, management and political support to health policies27. The third facilitator is the fact that the QualiSUS-Rede project, using thematic networks, prompted discussions on health care network planning, particularly in areas where previous experiences were scarce or nonexistent, with investment in strengthening primary care as the coordinator of care network9,28.
Barriers to QualiSUS-Rede implementation were predominantly related to external aspects such as excessive bureaucracy, prolonged tender processes, low administrative capacity, absence of knowledge about IBRD guidelines and lack of continuity in working groups, either by high management turnover or a decline in the development of subprojects due to electoral periods18.
The QualiSUS-Rede project made it possible to allocate additional resources to implement thematic care networks, which was well received by the players involved as an opportunity to improve access to health services and promote the integration of the system. This enthusiasm is mirrored in the literature, given that health care network implementation experiences in other international contexts have proven to be successful in integrating different levels of health care8,9,27,29. However, frustrations arose during the course of the project, due to the difficulties encountered in execution and integration with government funding available for thematic networks.
The inability of state and municipal government officials to deal with complex bureaucratic and administrative processes significantly prolonged the implementation of these subprojects. Proof of this is that three important metropolitan regions gave up on executing the subprojects.
The financial difficulties faced in the public sector are well known and recurrent in Brazil30,31. In the QualiSUS-Rede context, in addition to the legal constraints (federal, state and municipal), executing subprojects involved applying the Loan Agreement guidelines and required changes in the routines traditionally used by public administration. Requirements such as the need for administrative organization to participate in electronic reverse auction in regions without a structured electronic system, and previous authorization for a public call prepared by the states delayed the purchasing process. The authors believe that the deadlines were unreasonably short, since the deadlines had expired by the time officials finally familiarized themselves with the rules. A number of flaws corroborate this situation: “some of the things they (IBRD) wanted us to do for the project were impossible”, “the execution time was incompatible with the challenges”. For many of the individuals interviewed, the objective of the QualiSUS-Rede project was overly ambitious for the time allowed to achieve it. In its final report on QualiSUS-Rede implementation, the IBRD recognized these factors and described them as lessons learned32.
However, it is important to highlight that the projects located in the North and Northeast regions of the country, which may be insufficient, managed to advance more in some aspects in the organization of the RAS with the resources of QualiSUS-Rede33.
Furthermore, it was observed in this study that the interventions carried out by the subprojects were generic, that is, the training of primary care teams and improvement of infrastructure for primary and specialized care (hospitals)are important, but do not guarantee progress in the construction of the RAS. It would, therefore, be necessary to continue investing in strategic interventions such as implementing clinical guidelines and protocols, as well as improving the infrastructure of information and regulatory systems and others, to guarantee timely care within the RAS.
A fragmented health care system was also indicated as a barrier to implementing QualiSUS-Rede, reflecting the implementation of the SUS. For example, the decentralization of health policies assigned increasingly more responsibilities to individual municipalities, albeit unequally and more intensely in states and municipalities with above average infrastructure, resources and managerial capacity34. As such, there was little incentive to cooperate and integrate health services among municipalities, causing fragmented health care and compromising the SUS principles of universality and integrality8. Furthermore, when mechanisms were created to support health care services in 2000, they were essentially in the area of standardization, with little concrete experience in implementing RAS. Despite the progress in certain regions, this standardization was not sufficient to overcome the obstacles to regionalization and decentralization35. In this respect, QualiSUS-Rede was one of the first incentive strategies to put the organization of regionalized RAS into practice36.
the existence of multiple agents (governmental and non-governmental; public and private) involved in managing and providing health care;
the need to develop planning, administration, coordination, regulation and funding mechanisms and instruments for health service networks15,38;
the need to integrate the different health care services and economic and social policies aimed at development and reducing regional inequalities39.
Collaboration between the interested parties favored the creation of regional health plans, guided by the situational diagnoses performed. The outcome was better regional coordination through group meetings in the different regions, encouraging interaction between state and municipal entities. It is important that the parties comply with the guidelines established during monitoring, and that universities participate through their essential role in qualifying professionals17.
On the other hand, some groups that started with greater participation saw their role reduced during the process. This can be partly explained by the difficulty in building consensus on the priorities to be implemented. The lack of consensus, in some cases, resulted from the needs being greater than the resources available in QualiSUS-Rede. Moreover, there was disagreement among the individuals involved and conflicting interests, thereby hindering the work process27,40. Furthermore, some groups exhibited a lack of continuity, especially in the election year of 2014, when some activities were paralyzed17,18.
Some limitations of our study should be acknowledged. First, the interviews were conducted one year before the QualiSUS-Rede project was concluded. It is not clear whether this time lag influenced the perception of players regarding facilitators and barriers. Second, the results may not be generalizable to other healthcare contexts.
CONCLUSIONS
The QualiSUS-Rede project contributed to strengthening local governance and regional planning. However, barriers emerged in several aspects, from failure in prioritizing investments, opting for ambitious objectives to be achieved in a very short timeframe, to low local capacity to deal with bureaucratic and administrative obstacles.
DATA AVAILABILITY STATEMENT
The datasets generated and/or analyzed during this study are not publicly available due to privacy restrictions, but are available from the corresponding author upon request.
How to cite:
Oliveira MM, Shimizu HE, Ramos MC, Cruz MM, Silva EM. Challenges of implementation of the QualiSUS-Rede project in Brazil. Cad. Saúde Colet., 2026;34(2):e34020179. https://doi.org/10.1590/1414-462X202634020179
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Edited by
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Editor in charge:
Guilherme Werneck http://orcid.org/0000-0003-1169-1436
