Processos de trabalho e transição tecnologica na saude : um olhar a partir do Sistema Cartão Nacional de Saude

Abstract

Orientador: Emerson Elias MerhyTese (doutorado) - Universidade Estadual de Campinas, Faculdade de Ciencias MedicasResumo: Há um processo de informatização de serviços de saúde, no Brasil, protagonizado pelo Ministério da Saúde em parceria com os municípios. Isso é desenvolvido pelo projeto Sistema Cartão Nacional de Saúde (SCNS). No recorte teórico da pesquisa, discutiu-se, centralmente, a Composição Técnica do Trabalho (CTT) como analisadora dos processos produtivos da saúde e, portanto, ela deve revelar a possibilidade de mudança do modelo tecnoassistencial a partir do SCNS. A CTT é definida como a razão entre Trabalho Morto (TM) e Trabalho Vivo (TV) no interior dos processos de trabalho. Para discuti-la imaginou-se uma ¿Linha de Produção do Cuidado¿, que traz a imagem do fluxo realizado pelo usuário quando do encaminhamento de um determinado projeto terapêutico definido pelo profissional ou pela equipe que o assiste.O estudo parte do pressuposto de que o profissional, ao exercer seu trabalho, opera um núcleo tecnológico composto de ¿Trabalho Morto¿ (TM), máquinas e instrumentos; e ¿Trabalho Vivo¿ (TV). No modelo médico hegemônico, produtor de procedimentos, o processo de trabalho está centrado no Trabalho Morto, com uso excessivo de ¿tecnologias duras¿ e conhecimento especializado. Avaliamos que, dependendo da razão entre TM e TV, presentes no processo de trabalho, verificam-se mudanças no modo de produção da saúde que podem ocorrer em dois cenários diferentes: 1. há alteração no modo de produzir saúde, sem, no entanto, mudar a correlação entre TM e TV, o que caracteriza um processo de ¿reestruturação produtiva¿; 2. as mudanças significam também uma alteração na razão entre TM e TV, isto é, um processo de trabalho centrado no Trabalho Vivo no núcleo tecnológico do trabalho, caracterizando uma dada ¿transição tecnológica¿. Objetivos:Verificar até que ponto o SCNS impacta os processos de trabalho, provocando mudanças no modelo tecnoassistencial para a saúde.Metodologia: Estudo de campo, feito na Unidade Básica de Saúde Jardim Satélite, localizada na cidade de São José dos Campos, São Paulo. Desenho analítico proposto por MERHY (1998), que sugere avaliar o projeto SCNS nos aspectos da organização, da política e da produção do cuidado. Pesquisa bibliográfica e documental; entrevistas com informantes-chave. Foram aplicados o fluxograma descritor e a análise de relatórios. Foi feita simulação do funcionamento do sistema em laboratório.Principais resultados e conclusões: No campo da política, verifica-se, em primeiro lugar, que, no modo atual de operação do sistema de informações, o SCNS surge como mais um instrumento de controle do gestor federal (G) sobre o gestor municipal (g) e deste para os níveis locais. No campo da organização, o SCNS tem uma importante contribuição naquilo que, nos parece, é sua função precípua, ligada ao sistema de informações do SUS. A capacidade tecnológica de captura, transmissão e processamento de dados torna o sistema de informações teoricamente ágil e eficaz. No campo da produção do cuidado, concluiu-se que o SCNS tem sua vocação restrita ao sistema de informações, pois não opera mudanças no modelo tecnoassistencial. No analisador adotado para este estudo, o da Composição Técnica do Trabalho (CTT), verifica-se que o SCNS não altera a razão entre Trabalho Morto e Trabalho Vivo no núcleo tecnológico da produção do cuidado. Esta é a principal conclusão do estudoAbstract: The Health National Card System (¿Sistema Cartão Nacional de Saúde (SCNS)¿) is a project developed by the Ministry of Health from Brazil in partnership with the municipal districts. Its aim is similar to a process of having the Health Units computerized, where data are captured following the assistance given and such data are transferred to the superior management levels. Thus, the ¿SCNS¿ works as an instrument of a certain health information system. The problem to be discussed in this study is the verification of what is the impact caused by the ¿SCNS¿ in the work processes which arouses changes for health in a model that provides assistance and technique simultaneously. The focus on the issue is centralized in the micropolitics and the investigation was developed in the field of a Basic Health Unit from the municipal district of São José dos Campos, São Paulo, since it was the first municipal district to implant the ¿SCNS¿ and, therefore, provided enough maturation for such observation. According to the methodology, it was chosen an analytical draw proposed by MERHY (1998) which suggests an assessment of the project in the aspects of organization, policy and production of care. Besides the research into bibliography and documents carried out together with the Ministry of Health and companies working in the project, important informants in the Health Unit were interviewed, a chart with descriptions and reports analysis containing the data registered by workers were applied. Such reports were produced by the municipal server and compared to the Clinical Production Bulletin (¿Boletim de Produção Ambulatorial (BPA)¿) in the same period of time. It was made a verification in the Hypercom Company¿s laboratory in order to control possible variables of software interference in the results. Considering the theoretical scope of the research, it was mainly discussed the Technical Composition of Work (¿Composição Técnica do Trabalho (CTT)¿) as the analyzer of health productive processes and, thus, it should reveal the possibility of changing the model that provides assistance and technique simultaneously by the ¿SCNS¿. The ¿CTT¿ is defined as being the proportion between dead labor and living labor, within the work processes. Discussing such proportion it was figured out a Line of Care Production (¿Linha de Produção do Cuidado¿) which brings the flow¿s image made by the user during the process of a certain therapeutic project defined by the professional or the team who is responsible for it. It has been proved that the ¿CTT¿ is historical and socially defined and also has as a reference the constitution of the assistance models which are nowadays centered in the procedures production, working through hard and simultaneously soft and hard technologies, centered in dead labor, making a great capture of living labor. It has been also discussed two concepts related to the production of care. The first one, the one about Productive Restructuring, which presumably presents a new way to organize the health production without necessarily alter the composition of its technological nucleus, in other words, the proportion between dead labor and living labor. The second one, the Technological Health Transition¹, which means a new standard of production of care altering not only the way the productive process is organized, but also inverting the Technical Composition of Work, demonstrating the superiority of the living labor in the work processes which means working with assistance based in directions different from those present in the model ¿of medical superiority, producer of procedures¿ since it acts in accordance with users¿ needs. It was realized by the research results that the system works well for the functions of register, processing, transmission and storage data with subsequent reports production containing the required information. The issue stated at this point refers to the health workers acceptance of this new function which means taking electronic notes of data. The system will solely work well whether workers utilize such function fully. The ¿SCNS¿ causes impact in the changes of workers functional standard when includes computers skills and terminals operation as part of their knowledge and practice in health since these are new functions. They refer to the apparatus that builds Human Resources to health and to the issues related to the worker¿s ergonomics and health to be analyzed according to the new activities. Regarding the data electronic register, which are many, the biggest difficulties are in the notes of medical consultation. This occurs because it is exactly where most of the information is, such as nosology, registered through the code of the International Classification of Diseases (¿Classificação Internacional de Doenças (CID)¿), the procedures, medicines prescriptions, examinations and directions. Furthermore, the doctor is under pressure due to the time limit he has for other consultations which can cause a not so good data register or even incomplete notes. Regarding the policy, it is firstly verified that in the present way of the information system operation, the ¿SCNS¿ arises as one more instrument of federal management (G) to control the municipal management (g) and from them to the local levels. Such thing occurs because the system works capturing and transmitting data to the superior management levels with no return and has a systematics of processing problems verified through the information generated in this process. In the implantation process, there was a great agreement between the Ministry of Health (MS) and the municipal districts of pilot project, assuming that, although the Ministry of Health is responsible for the decisions and regulation of the whole project, for the municipal district is essential to have it done for the resources available and for the concerns about the project¿s operation. In the organization field, it was necessary to mobilize a great amount of hardware resources due to the project¿s extension in its pilot phase. These hardware and software resources are all under the Ministry of Health¿s control and are supplied and developed by Hypercom Company, concerning the case in study, from São José dos Campos. The municipal district needs to arrange for the project resources such as telephone lines, electrical energy and appropriate places in the Health Units, to have the terminals and other equipment as well as the room where the municipal server should be kept. Besides that, it will be necessary human resources for the project, especially to operate the municipal server. Regarding the management, the ¿SCNS¿ gives an important contribution which is considered to be its main function linked to the information system of ¿SUS¿. The technological capacity to capture, transmit and process data makes the information system theoretically agile and effective. In the field of production of care, it was concluded that the ¿SCNS¿ has its competence restricted to the information system since it does not make any changes in a model that provides assistance and technique simultaneously. According to the analyzer accepted for this study, the Technical Composition of Work (¿Composição Técnica do Trabalho (CTT)¿), it has been verified that the ¿ SCNS¿ does not alter the proportion between dead labor and living labor in the technological nucleus of production of care. This is the main conclusion of this studyDoutoradoDoutor em Saude Coletiv