Challenges to implementing planning processes in Brazilian health regions

Tanaka, Oswaldo Yoshimi; Akerman, Marco; Louvison, Marília Cristina Prado; Bousquat, Aylene; Pinto, Nicanor Rodrigues da Silva; Meira, Ana Lígia Passos; Godoi, Lídia Pereira da Silva; Pereira, Ana Paula Chancharulo e Morais; Spedo, Sandra Maria; Oliveira, Monique Batista de; Eshriqui, Ilana; Paresque, Marcio Anderson Cardozo

doi:10.11606/s1518-8787.2023057005138

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Original Article • Rev. Saúde Pública 57 (Suppl 3) • 2023 • https://doi.org/10.11606/s1518-8787.2023057005138 linkcopy

Challenges to implementing planning processes in Brazilian health regions

Authorship SCIMAGO INSTITUTIONS RANKINGS

OBJECTIVE To recognize elements that facilitated or hindered the PlanificaSUS implementation stages.

METHODS A multiple case study was carried out in four pre-selected health regions in Brazil—Belo Jardim (PE), Fronteira Oeste (RS), Sul-Mato-Grossense (MT) and Valença (BA) using systemic arterial hypertension and maternal and child care as tracer conditions. Participant observation (in regional interagency commissions) and in-depth interviews with key informants from state and municipal management and primary health care and specialized outpatient care service professionals within the project were carried out in these four regions. Analysis was built according to political, technical-operational, and contextual dimensions.

RESULTS The political dimension evinced that the regions found the project an opportunity to articulate states and municipalities and an important political bet to build networks and lines of care but that there remained much to be faced in the disputes related to building the Unified Health System (SUS). In the technical operational dimension, it is important to consider that primary health care stimulated a culture of local planning and favored traditional tools to organize and improve it, such as organizing registrations, agendas, and demands. However, centralized training and planning-inducing processes fail to always respond to local needs and can produce barriers to implementation.

CONCLUSIONS It is worth considering the central and regional role of state managers in the commitment related to the project and the effect of mobilizing primary health care and expanding its power. There remains much to be faced in the disputes at stake in bullring SUS.

Primary Health Care; Regionalization Health Planning; Health Planning Support

Institutional affiliation of the interviewee	Health Regions

	BA		MT		PE		RS		Total

	Stage 1	Stage 2	Stage 1	Stage 2	Stage 1	Stage 2	Stage 1	Stage 2	Stage 1	Stage 2
SHS Management
Central	1	2	2	3	6	4	2	5	11	14
Regional	-	-	4	-	5	5	5	5	14	10
MHS Management
Large municipality	3	1	3	2	3	3	4	1	13	7
Small municipality	4	1	2	1	3	5	1	1	10	8
UBS-Lab
Large municipality	3	-	1	1	3	3	2	1	9	5
Small municipality	5	-	2	-	3	2	2	2	12	4
Specialized care outpatient clinic	1	-	2	1	5	2	3	-	11	3
Total	17	4	16	8	28	24	19	15	80	51

Prism
Policies (and social actors)	Operational-Technical	Context
State level	PHC	Internal
Regional level	SOC	External
Municipal level	Regulation of access to SOC

Facilitating factors
Political support from SHS	SHS Central Level Engaged
	Existence of projects for the organization of specialized care under SHS management prior to PlanificaSUS—participation of primary care coordination or advisory
	The SHS institutional support strategy enabled the systematic monitoring of planning implementation
Inter-municipal consortium	Political valorization of the consortium format
Inter-municipal consortium	Initiatives to create regional health polyclinics with the participation of municipalities
SHS Regional Management	An important political actor supporting municipalities but with different weight across regions
Municipal managers of SUS	They believe that PlanificaSUS improves PHC and, in a way, facilitates access to SOC
Small municipalities	Important political actors to reorganize work processes in PHC
Small municipalities	Maintained consistent adherence to PlanificaSUS
Hindering elements
Conflicts in secondary level organization	Conflicting interests between civil servants and the SHS regional structure
Tensions between MHS and SHS	Insufficient funding, lack of transfers of resources (from SHS to MHS)
Tensions between MHS and SHS	Different forms of management of SOC, in general, with a greater leading role of the state entity
Tensions with private (philanthropic) providers	Locoregional divergences on the organization and implementation of SOC (autonomy of providers without public management regulation)
	Conflicting relationship between MHS and private provider hospitals (Santas Casas) in SOC management
	Contractualization by central SHS with little or no regional participation hinders the construction/agreement of a regional SOC project
Fragility of collegiate bodies	Fragility of the RIC Technical Chambers
Constant change of municipal and state managers	Frequent change of managers and management guidelines in municipalities weakened in agreements
Constant change of municipal and state managers	Change of central and regional state SUS managers

Facilitating factors
Involvement of service professionals	Valuing capillary planning among professionals
Incorporation of PlanificaSUS tools	Planning tools built into local plans
	Incorporation into PHC work processes
	Use of planning instruments in PHC care activities
Hindering elements
Insufficient budget forecasting for all needs	Unforeseen costs to develop PlanificaSUS hindered the participation of several municipalities
Insufficient budget forecasting for all needs	Lack of operational alternatives to adapt to the project
Lack of flexibility in the PlanificaSUS model	Strategies to implement PlanificaSUS: barely open to locoregional adaptations
Lack of flexibility in the PlanificaSUS model	Rigidity in task control
Less involvement of other areas of management in the operation of the project	Little involvement of other strategic sectors of the SES beyond primary care

Facilitating factors
Cumulative frequency	Some articulation initiatives between PHC and SOC
	Existing lines of care and those being implemented in the regions, facilitating adherence
	SHS previous planning experience
Organization and articulation of municipal managers	Prior articulation of local municipalities
Organization and articulation of municipal managers	Prior sharing of services and funding
Hindering elements
Management of SUS work (SHS and MHS)	Frequent losses of health workers in care teams (administrative reform; precarious employment contracts; extinction of the More Doctors Program; COVID-19 pandemic)
Management of SUS work (SHS and MHS)	The pandemic has completely changed the work processes of laboratory units and the secondary level
Relationship between MHS, SHS, and MH	Municipalities found insufficient support from the SHS to implement lines of care
Relationship between MHS, SHS, and MH	Changes in the national PHC policy impacted PlanificaSUS
Pandemic	Increased PHC workload and occasional closure of SOC
Pandemic	Constant absence of professionals

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[TFN1] SHS: State Secretariat of Health; MHS: Municipal Health Secretary; UBS: basic health unit; Mun.: municipality; BA: Bahia; MT: Mato Grosso; PE: Pernambuco; RS: Rio Grande do Sul.