Práticas de planejamento e implementação de políticas no âmbito municipal

Capacidade de governo em Secretarias Municipais de Saúde

RESUMO A partir da descentralização da gestão Sistema Único de Saúde (SUS), surge a necessidade de se discutir a capacidade de governo, ou de gestão, no âmbito municipal, para a implementação dessa política. Este estudo objetiva analisar a capacidade de governo de Secretarias Municipais de Saúde em municípios baianos, tendo por base a experiência dos gestores. Foi aplicado questionário on-line, subdividido em 03 dimensões, a 15 gestores representantes de Secretarias de municípios de pequeno (porte I) e grande porte (porte II), nas 09 macrorregiões de saúde do estado. Foi utilizada uma matriz de pontuação, que permitiu a quantificação e a classificação dos municípios em cada uma das dimensões e quanto à sua capacidade de governo. Obteve-se que 12 dos municípios apresentaram capacidade moderada, e 03 apresentaram baixa capacidade de governo. A dimensão relacionada ao desenho organizativo das Secretarias foi aquela em que os municípios apresentaram melhor desempenho, seguida por sistemas de trabalho nessas organizações e trajetória profissional dos gestores. Ainda, municípios de porte I e os situados em regiões mais desenvolvidas obtiveram melhores resultados globais. Para a qualificação das gestões, considera-se essencial o investimento em iniciativas de formação e de apoio institucional, priorizando municípios de pequeno porte e situados em regiões de maior vulnerabilidade socioeconômica.

Intersectorality in the 'Health in Schools' Program: an evaluation of the political-management process and working practices

This study analyzed inter-sectoral activities between the health and education sectors in implementing the Health in Schools program in a city within a metropolitan region in northeast Brazil. Analysis of the political-management process looked at the following dimensions: professional practices and subject understanding of intersectorality. The results show that subjects define intersectorality as partnership and joint efforts. Regarding decision making and resource mobilization, during program implementation we noticed that healthcare leads, and education tends to play a more peripheral role. Health activities in the schools use a biomedical approach and primarily consist of lectures. We believe that the program strengthened the relationship between these two sectors. However, intersectoral coordination in the political-management process and practices show weaknesses and limitations.

[Validation of the theoretical logical model for food and nutritional surveillance in primary care]

The aim of this study was to describe the stages in the development and results of the validation of the theoretical logical model for food and nutritional surveillance in primary healthcare (PHC). This was a descriptive and exploratory study that involved 20 specialists in food and nutrition, including researchers, policymakers, health professionals, and users based on a consensus technique in two rounds. Participants classified the structural components needed for food and nutritional surveillance and the respective expected results according to pertinence and relevance. The items were defined as consensus when they reached more than 80% agreement among participants, confirmed by the analysis of the median and interval between the first and third quartiles. The results reflect the validated content of the matrices organized according to four technical components: strategic planning, administrative planning, management and organization of practices, and monitoring and evaluation. The structure and necessary processes for conducting food and nutritional surveillance activities in PHC and the expected short-, medium-, and long-term results were described in the theoretical logical model. The validation of the theory of functioning of the intervention met its objective of increasing the content and construct validity and support the analytical generalization of the case-studies method, a strategy adopted to evaluate the implementation of food and nutritional surveillance in a specified context, in addition to creating a space for dialogue between the theory and its critique by involving different stakeholders in the evaluation, as well as providing a useful management tool.

Access to medicines: relations with the institutionalization of pharmaceutical services

OBJETIVE

To analyze the relationship between access to medicines by the population and the institutionalization of pharmaceutical services in Brazilian primary health care.

METHODS

This study is part of the Pesquisa Nacional sobre Acesso, Utilização e Promoção do Uso Racional de Medicamentos - Serviços 2015 (PNAUM - National Survey on Access, Use and Promotion of Rational Use of Medicines - Services 2015), a cross-sectional, exploratory, and evaluative study composed of an information survey in a representative sample of cities, stratified by Brazilian regions. Access was defined based on the acquisition of medicines reported by the patient, ranging between: total, partial, or null. The institutionalization of pharmaceutical services was analyzed based on information provided by pharmaceutical services providers and by those responsible for medicines delivery. Chi-square test and multinomial logistic regression were used in the statistical analysis.

RESULTS

Full access to medicines was greater when professionals affirmed there were the following aspects of the dimensions: "management tools," "participation and social control," "financing," and "personnel structure," with significant associations in the bivariate analysis. The "pharmaceutical care" dimension did not achieve such an association. After multinomial logistic regression, full access was more prevalent when those in charge of pharmaceutical services stated that: they always or repeatedly attend meetings of the Municipal Health Council, OR = 3.3 (95%CI 1.5-7.3); there are protocols for medicines delivery, OR = 2.7 (95%CI 1.2-6.1); there is computerized system for managing pharmaceutical services, OR = 3.9 (95%CI 1.9-8.0); those responsible for medicines delivery reported having participated in a course or training for professionals in the past two years, OR = 2.0 (95%CI 1.1-3.5); there is computerized system for pharmaceutical services management, OR = 4.3 (95%CI 2.4-7.5).

CONCLUSIONS

Aspects related to the institutionalization of pharmaceutical services have been strongly related to access to medicines. Our results indicate the need to prioritize its implementation, contributing to its consolidation in Brazil and to the effectiveness of health services regarding the purposes of pharmaceutical services policies.

Saúde Pública e Políticas Públicas: campos próximos, porém distantes

Resumo Este artigo trabalha com as contribuições que o campo das políticas públicas pode trazer para o entendimento das instituições, atores e processos envolvendo a saúde pública. Fundamenta-se no fato de que muitos dos trabalhos sobre políticas públicas em saúde tendem a descrevê-las e/ou analisá-las, mas poucos se utilizam do ferramental próprio das análises de políticas públicas, campo amplo de conhecimento já bastante disseminado no Brasil. Neste sentido, o artigo visa estimular o debate interdisciplinar entre os dois campos - saúde pública e políticas públicas -, entendendo-os como complementares conceitual e empiricamente, mas ainda distantes nas análises da literatura nacional sobre saúde pública. O artigo propõe, a partir de uma breve revisão sobre o conceito de “ciclo de políticas públicas”, que este e sua bibliografia foram incorporados de maneira insuficiente aos estudos sobre políticas de saúde, o que ficou demonstrado pela análise dos artigos publicados na revista Saúde e Sociedade entre os anos 2005 e 2015 (627 artigos analisados). Conclui-se apontando caminhos e desafios para a aproximação entre os dois campos.

[Managing comprehensive care: a case study in a health district in Bahia State, Brazil]

This study analyzed management of comprehensive care in a health district in Bahia State, Brazil, at the political, institutional, organizational, and healthcare practice levels and the challenges for establishing coordinated care between municipalities. The information sources were semi-structured interviews with administrators, focal groups with healthcare professionals and users, institutional documents, and observations. A comprehensive and critical analysis was produced with dialectical hermeneutics as the reference. The results show that the Inter-Administrators Regional Commission was the main regional governance strategy. There is a fragmentation between various points and lack of communications linkage in the network. Private interests and partisan political interference overlook the formally agreed-upon flows and create parallel circuits, turning the right to health into currency for trading favors. Such issues hinder coordination of comprehensive care in the inter-municipal network.

[Autonomy for financial management in public and private healthcare facilities in Brazil]

Autonomy in financial management is an advantage in public administration. A 2009 National Healthcare Facility Survey showed that 3.9% of Brazil's 52,055 public healthcare facilities had some degree of financial autonomy. Such autonomy was more common in inpatient facilities (17.8%), those managed by State governments (26.3%), and in Southern Brazil (6.6%). Autonomy was mainly partial (for resources in specific areas, relating to small outlays, consumables and capital goods, and outsourced services or personnel). 74.3% of 2,264 public facilities with any financial autonomy were under direct government administration. Financial autonomy in public healthcare facilities appears to be linked to local political decisions and not necessarily to the facility's specific legal and administrative status. However, legal status displays distinct scopes of autonomy - those under direct government administration tend to be less autonomous, and those under private businesses more autonomous; 85.8% of the 45,394 private healthcare facilities reported that they were financially autonomous.

[Critical issues for implementing oral health policy in the city of Salvador, Bahia State, Brazil]

This study focuses on policy implementation by public organizations. This was a qualitative, exploratory case study focusing on Brazil's National Oral Health Policy, known as "Smiling Brazil", implemented in Salvador, the State capital of Bahia. The study aimed to identify factors that facilitated or hindered the policy's implementation, based on the public policy cycle and Carlos Matus' government triangle concept, for the period from 2004 to 2007. Data collection strategies included analysis of municipal documents, interviews with key informants, and direct observation of top management meetings at the Municipal Health Secretariat. The main factors that hindered implementation of the municipal oral health policy were the project's lack of specificity; lack of human resources; and lack of financial autonomy in the Municipal Health Secretariat. The study showed that the lack of connection between the variables comprising the government triangle raised obstacles to the implementation of oral health policy in Salvador.

Alcohol prevention within primary care in municipalities in the state of Minas Gerais, Southeastern Brazil

OBJECTIVE

To evaluate the effectiveness of implementing screening strategies associated with brief interventions for prevention of alcohol abuse, within primary healthcare.

METHODS

This evaluation study was conducted among 113 primary healthcare professionals and managers in three municipalities in the Zona da Mata of Minas Gerais, Southeastern Brazil, in 2007. The health professionals participated in a training to perform screening associated with brief interventions for alcohol use prevention. Six months after this training, a follow-up evaluation was carried out. The qualitative assessment involved participant observation, interviews with managers before the training and during the follow-up, and focus groups with healthcare professionals during the follow-up. The content analysis technique was applied. The following instruments were used for the quantitative assessment: Objective Knowledge Questionnaire, Moralization Scale for Alcohol Use, Perception Model for Alcohol Use Questionnaire and Preventive Practices for Alcohol Use Questionnaire. The municipalities were compared before the training and during the follow-up, and longitudinal evaluations were performed in each municipality, using descriptive and inferential statistics.

RESULTS

Participation by the managers and integration among the health professionals regarding the practices of screening and brief intervention were associated with greater effectiveness of implementation. This occurred in one of the municipalities, in which there was a significant decrease in the degree to which alcohol use was moralized by the healthcare professionals, in comparison with the other municipalities. In the other municipalities, the effects of the implementation process for the project indicated that the frequency of performing preventive practices against alcohol use increased, along with the health professionals' knowledge, although not enough to indicate effective implementation.

CONCLUSIONS

Effectiveness in implementing alcohol prevention strategies in primary healthcare services is associated with managers' engagement in the implementation process for these strategies.

Saúde mental na atenção básica: um estudo epidemiológico baseado no enfoque de risco

As transformações de cunho social-político e econômico ocorrido nas últimas décadas repercutem em todos os setores da sociedade. Fato que traz transformações para a saúde mental da população. Teve como objetivo realizar a população com risco para adoecimento mental. Trata-se de um estudo epidemiológico de corte transversal realizado em uma comunidade de João Pessoa-PB, utilizando-se Self Report Questionnaire-20 (SRQ-20). Observou-se associação do Risco para Depressão e Ansiedade com o sexo feminino (59,40%), faixa etária de 40 a 65 anos (66%), ocupação de serviços domésticos (65,5%). Somos levados a reconhecer que o sofrimento mental tem crescido relativamente na amostra estudada e a partir dessa constatação faz-se necessário uma atenção imediata aos problemas de saúde mental nas pessoas da comunidade.