Governança regional: estratégias e disputas para gestão em saúde

OBJECTIVE To analyze the regional governance of the health systemin relation to management strategies and disputes. METHODOLOGICAL PROCEDURES A qualitative study with health managers from 19 municipalities in the health region of Bahia, Northeastern Brazil. Data were drawn from 17 semi-structured interviews of state, regional, and municipal health policymakers and managers; a focus group; observations of the regional interagency committee; and documents in 2012. The political-institutional and the organizational components were analyzed in the light of dialectical hermeneutics. RESULTS The regional interagency committee is the chief regional governance strategy/component and functions as a strategic tool for strengthening governance. It brings together a diversity of members responsible for decision making in the healthcare territories, who need to negotiate the allocation of funding and the distribution of facilities for common use in the region. The high turnover of health secretaries, their lack of autonomy from the local executive decisions, inadequate technical training to exercise their function, and the influence of party politics on decision making stand as obstacles to the regional interagency committee’s permeability to social demands. Funding is insufficient to enable the fulfillment of the officially integrated agreed-upon program or to boost public supply by the system, requiring that public managers procure services from the private market at values higher than the national health service price schedule (Brazilian Unified Health System Table). The study determined that “facilitators” under contract to health departments accelerated access to specialized (diagnostic, therapeutic and/or surgical) services in other municipalities by direct payment to physicians for procedure costs already covered by the Brazilian Unified Health System. CONCLUSIONS The characteristics identified a regionalized system with a conflictive pattern of governance and intermediate institutionalism. The regional interagency committee’s managerial routine needs to incorporate more democratic devices for connecting with educational institutions, devices that are more permeable to social demands relating to regional policy making.OBJETIVO Analisar o sistema de governança regional em saúde quanto a estratégias e disputas de gestão. PROCEDIMENTOS METODOLÓGICOS Pesquisa qualitativa com gestores de saúde de 19 municípios que integram a região de saúde no estado da Bahia. Foram realizadas 17 entrevistas semiestruturadas com gestores/gerentes (estadual, regional e municipal), grupo focal, observações na Comissão Intergestores Regional e documentos institucionais, em 2012. Foram analisados os componentes político-institucional e organizacional e interpretados pela hermenêutica-dialética. RESULTADOS A comissão intergestores regional foi a principal estratégia da governança regional, sendo ferramenta fundamental para fortalecimento da governança por reunir diferentes sujeitos responsáveis pela tomada de decisão nos territórios sanitários e pela negociação da alocação de recursos e distribuição dos estabelecimentos de uso comum na região. A rotatividade de secretários de saúde, baixa autonomia nas decisões executivas, a qualificação técnica insuficiente para exercício da função e o atravessamento das políticas partidárias na tomada de decisão são fatores que obstruem a comissão intergestores regional às demandas sociais. Recursos financeiros insuficientes não viabilizam o cumprimento da programação pactuada integrada nem o aumento da oferta pública na rede e impunham ao gestor a compra de serviços no mercado privado por valores acima da Tabela do Sistema Único de Saúde. Foram relatados atravessadores contratados para agilizar o acesso aos serviços especializados (diagnóstico, terapêutico e/ou cirúrgico) em outros municípios mediante pagamento direto a médicos por procedimentos já custeados pelo Sistema Único de Saúde. CONCLUSÕES A rede regionalizada de saúde apresenta padrão de governança conflitante e com institucionalidade intermediária. A comissão intergestores regional necessita incorporar, à rotina de gestão, dispositivos mais democráticos que logrem articulação com instituições de ensino, permeáveis às demandas sociais, para definição das políticas regionais

Advanced Practice Nursing in Primary Health Care in the Spanish National Health System

Hämel K, Toso BRG de O, Casanova A, Giovanella L. Advanced Practice Nursing in Primary Health Care in the Spanish National Health System. Ciência &amp; Saúde Coletiva. 2020;25(1):303-314.Abstract The primary health care in the Spanish National Health System is organised in health centres with multi-professional teams, composed of doctors and nurses specialised in family and community health, in addition to other professionals. This article analyses the role of primary health care nurses in the Spanish National Health System. In the last decade, new concepts of task sharing between doctors and nurses as well as advanced nursing roles have been evolved in the health centres that focus on improving care for chronically ill patients and access to primary care. With shared responsibility, nurses are responsible for chronic patients in stable conditions, health prevention and promotion. The scaling up of advanced nursing tasks is limited by uncertainties of roles, disparities between states, and legislations that do not cover the full extent of advanced nursing tasks. The case study of Spain indicates that a strong multi-professional model of primary health care teams is a crucial basis for the evolvement of advanced nursing practice and its acceptance in daily routines. However, advantageous education structures and legislations are needed to allow nurses to develop their contribution in the full potential.</jats:p

Extensão de Cobertura ou Reorganização da Atenção Básica? A trajetória do Programa de Saúde da Família de Manaus-AM

This paper analyzes seven years of implementation of Programa Saúde da Família (PSF - Family Health Program) in the city of Manaus, state of Amazonas, aiming at identifying its influence on changes in the municipal health care system that are capable of contributing to the reduction in health care inequalities. It contextualizes the genesis of the PSF in the municipality, its characteristics, contradictions and limitations, thus investigating whether the program has built only a coverage extension history or whether it has effectively contributed to the reorganization of the primary health care model. The analysis categories prioritized specific management principles of the PSF: substitutive nature, integration with institutions and social organizations, territorialization, situational planning based on the family and community, popular participation and social control. The methodology was qualitative-quantitative, including the analysis of data from two studies evaluating the implementation of the PSF in the municipality, carried out in 2001 and 2006. The results show that, in Manaus, the PSF is a coverage extension strategy, with partial superposition on the preexisting primary medical care structure and parallelism of actions. Given the conditions of its implementation we conclude that the PSF expresses itself as an isolated program within the municipal health care system, with the potentiality to become a restructuring strategy of primary health care in Manaus. The confluence with the implementation of the Sanitary Districts may be able to contribute to redirect the medical attention model, thus assuring integral care and concretizing the right to health.Este trabalho analisa sete anos de implantação do Programa de Saúde da Família (PSF) de Manaus, procurando identificar mudanças no sistema municipal de saúde a ele relacionadas e capazes de contribuir para a redução de desigualdades em saúde. Contextualiza a gênese do PSF no município, suas características, contradições e limitações, investigando se o programa construiu apenas uma trajetória de extensão de cobertura ou contribuiu efetivamente para a reorganização do modelo de atenção básica à saúde. As categorias de análise priorizaram princípios específicos de gestão do PSF: caráter substitutivo, integração com instituições e organizações sociais, territorialização, planejamento situacional com base na família e na comunidade, participação popular e controle social. A metodologia utilizada foi quali-quantitativa, compreendendo a análise dos dados de duas pesquisas avaliativas da implementação do PSF no município, realizadas em 2001 e em 2006. Os resultados mostram que, em Manaus, o PSF se constitui em uma estratégia de extensão de cobertura, com parcial superposição à estrutura assistencial de atenção básica (AB) preexistente e paralelismo de ações. Dadas as condições de sua implantação, conclui-se que o PSF se expressa como um programa isolado dentro do sistema municipal de saúde, com potencialidade para se converter em estratégia reestruturadora da AB em Manaus. A confluência com a implantação dos Distritos Sanitários poderá contribuir para um caminho de reorientação do modelo assistencial que garanta atenção integral e concretize o direito à saúde

Barriers to and enablers of the promotion of patient and family participation in primary healthcare nursing in Brazil, Germany and Spain: A qualitative study

Cuidador familiar; Educació del pacient; Participació del pacientCuidador familiar; Educación del paciente; Participación del pacienteFamily Caregiver; Patient education; Patient participationBackground: Most health systems are insufficiently prepared to promote the participation of chronically ill patients in their care. Strong primary health care (PHC) strengthens patients' resources and thus promotes their participation. The tasks of providing continuous care to people with chronic diseases and promoting self‐ management are the responsibility of PHC nurses. Recent research assessing enablers of or barriers to nurses' efforts to support patients' participation has mostly not considered the special situation of patients with chronic diseases or focused on the PHC setting. Objective: To investigate enablers of and barriers to PHC nurses' efforts to promote the participation of chronically ill patients in their care. Methods: We interviewed 34 practicing PHC nurses and 23 key informants with advanced knowledge of PHC nursing practice in Brazil, Germany and Spain. The data was analyzed using thematic coding. Results: We identified four categories of barriers and enablers. (1) Establishing bonds with patients: Interviewees emphasized that understanding patients' views and behaviours is important for PHC nurses. (2) Cooperation with relatives and families: Good relationships with families are fundamental, however conflicts within families could challenge PHC nurses efforts to strengthen participation. (3) Communication and cooperation within PHC teams: PHC nurses see Cooperative team structures as a potential enabler, while the dominance of a ‘biomedical’ approach to patient care is seen as a barrier. (4) Work environment: Interviewees agreed that increased workload is a barrier to patient participation. Discussion and Conclusions: Supporting patient participation should be acknowledged as an important responsibility for nurses by general practitioners and PHC planners. PHC nurses should be trained in communicative competence when discussing participation with chronically ill patients. Interprofessional education could strengthen other professionals' understanding of patient participation as a nursing task. Patient or Public Contribution: This study is part of a research project associated with the research network ‘forges: User‐oriented care: Promotion of health in the context of chronic diseases and care dependency’. The study's focus and provisional results were discussed continuously with partners in health and social care practice and presented to and discussed with the public at two conferences in which patient representatives, professionals and researchers participated

Family Health Strategy in Brazil - Shaping the profile of nursing in primary health care

Hämel K, Backes DS, Giovanella L, Büscher A. Familiengesundheitsstrategie in Brasilien - Profilierung der Pflege in der Primärversorgung. Pflege &amp; Gesellschaft. 2017;22(1):35-50

Barriers to and enablers of the promotion of patient and family participation in primary healthcare nursing in Brazil, Germany and Spain: A qualitative study

Background Most health systems are insufficiently prepared to promote the participation of chronically ill patients in their care. Strong primary health care (PHC) strengthens patients' resources and thus promotes their participation. The tasks of providing continuous care to people with chronic diseases and promoting self-management are the responsibility of PHC nurses. Recent research assessing enablers of or barriers to nurses' efforts to support patients' participation has mostly not considered the special situation of patients with chronic diseases or focused on the PHC setting. Objective To investigate enablers of and barriers to PHC nurses' efforts to promote the participation of chronically ill patients in their care. Methods We interviewed 34 practicing PHC nurses and 23 key informants with advanced knowledge of PHC nursing practice in Brazil, Germany and Spain. The data was analyzed using thematic coding. Results We identified four categories of barriers and enablers. (1) Establishing bonds with patients: Interviewees emphasized that understanding patients' views and behaviours is important for PHC nurses. (2) Cooperation with relatives and families: Good relationships with families are fundamental, however conflicts within families could challenge PHC nurses efforts to strengthen participation. (3) Communication and cooperation within PHC teams: PHC nurses see Cooperative team structures as a potential enabler, while the dominance of a ‘biomedical’ approach to patient care is seen as a barrier. (4) Work environment: Interviewees agreed that increased workload is a barrier to patient participation. Discussion and Conclusions Supporting patient participation should be acknowledged as an important responsibility for nurses by general practitioners and PHC planners. PHC nurses should be trained in communicative competence when discussing participation with chronically ill patients. Interprofessional education could strengthen other professionals' understanding of patient participation as a nursing task. Patient or Public Contribution This study is part of a research project associated with the research network ‘forges: User-oriented care: Promotion of health in the context of chronic diseases and care dependency’. The study's focus and provisional results were discussed continuously with partners in health and social care practice and presented to and discussed with the public at two conferences in which patient representatives, professionals and researchers participated

Familiengesundheitszentren in Brasilien (Unidades básicas de saúde, Clínicas da Família)

Hämel K, Schaeffer D, Büscher A, Backes DS, Giovanella L. Familiengesundheitszentren in Brasilien (Unidades básicas de saúde, Clínicas da Família). PORT – Patientenorientierte Zentren zur Primär- und Langzeitversorgung. Stuttgart: Robert Bosch Stiftung; 2018