Abstract

This study aims to characterize the teams and the inter-professional work process of Matrix Support developed and practiced in primary healthcare provided by the Brazilian Unified Health System (SUS) in Campinas, São Paulo State, Brazil. This is an exploratory descriptive study involving a questionnaire that was applied to 232 professionals who practice Matrix Support for primary healthcare. For analysis, the data were grouped into four categories: Identification of the professional; Work links to the Campinas SUS; Organization of the Matrix Support work; and the Support practice. The study indicates that the methodology of support for inter-professional work has achieved an important degree of consolidation in the municipality, in spite of the restricted investment. The reduced working time dedicated to support, and the large number of teams supported by each Matrix Support team were identified as the principal points of fragility in the work process. In turn, strong points that emerged were the multiplicity of tools used, the possibility of shared construction of work guidelines, and the flexibility in the composition of the support teams. Both the fragilities and the potentialities found can offer inputs for reflection and full creation of Matrix Support in other contexts.

Health policies; Health planning and administration; Matrix Support; Primary Healthcare

In recent decades, Matrix Support has been defined as a strategy for co-management for inter-professional work in a network. This definition gives value to the amplified conception of the health/illness process, inter-disciplinarity, dialog, and interaction between professionals who work in teams or in health networks and systems¹1. Campos GWS. Equipes de referência e apoio especializado matricial: um ensaio sobre a reorganização do trabalho em saúde. Cien Saude Colet 1999; 4(2):393-403.

2. Campos GWS, Domitti AC. Apoio matricial e equipe de referência: uma metodologia para gestão do trabalho interdisciplinar em saúde. Cad Saude Publica 2007; 23(2):399-407.

3. Figueiredo MD, Onocko Campos R. Saúde Mental na atenção básica à saúde de Campinas, SP: uma rede ou um emaranhado? Cien Saude Colet 2009; 14(1):129-138.^-44. Cunha GT, Campos GWS. Apoio Matricial e Atenção Primária em Saúde. Saúde Soc 2011; 20(4):961-970..

This strategy of co-management for organization of work was formulated at the beginning of the 1990s and began to be implemented at the initiative of professionals of the SUS network of Campinas (São Paulo State), beginning in the area of mental health and primary care⁵5. Braga Campos FC. O modelo da reforma psiquiátrica brasileira e as modelagens de São Paulo, Campinas e Santos [tese]. Campinas: Universidade Estadual de Campinas; 2000. and expanding subsequently to other areas of specialized knowledge.

Over the period 2001 to 2004 this strategy was adopted as policy of the Municipal Health Department and encouraged by incentive through offer of training courses in Institutional Analysis, Handling of Groups and other themes related to Matrix Support for the professionals and managers involved with this practice⁶6. Fernandes JA. Apoio Institucional e cogestão: uma reflexão sobre o trabalho dos Apoiadores do SUS Campinas [dissertação]. Campinas: Universidade Estadual de Campinas; 2014.^,77. Oliveira MM. Apoio Matricial na Atenção Básica de Campinas: formação e prática. [dissertação]. Campinas: Universidade Estadual de Campinas; 2014..

In spite of the good progress made by these actions over more than a decade, it was possible to see that as from 2005 until the moment of this survey, various measures had prejudiced the development of the method referred to: the municipal management ceased to adopt Matrix Support as a government directive; it reduced the investments in primary healthcare and in training of professionals; and working conditions increasingly deteriorated⁸8. Fernandes JA, Figueiredo MD. Apoio institucional e cogestão: uma reflexão sobre o trabalho dos apoiadores do SUS Campinas. Physis 2015; 25(1):287-306.. However, it is perceived that Matrix Support continued to be incorporated into the discourse and practices of numerous professionals of primary and specialized healthcare.

At present the municipality of Campinas (SP) has its own healthcare network comprising 63 Primary Healthcare Units; 5 Health Supervision Centers; 18 referral units with specialized care, of which 3 are multi-clinics providing outpatient care for approximately 30 medical specialties, 11 are Psychosocial Care Centers of the Mental Health area, 1 an outpatient unit of CEASA, and other units dedicated to Physical Rehabilitation, Child Life Experience, Workers’ Health, Elderly People’s Health, Adolescent Health, Sexually Transmissible Diseases and AIDS; 2 are municipal hospitals, 4 are Household Care Services; 6 are Community Health Centers; and 7 are care units for emergency cases⁹9. Prefeitura Municipal de Campinas. Secretaria Municipal de Saúde. Unidades de Saúde. [acessado 2015 nov 16]. Disponível em: http://2009.campinas.sp.gov.br/saude/
http://2009.campinas.sp.gov.br/saude/... ^,1010. Serviço de Saúde Dr. Candido Ferreira. Unidades Assistenciais. [acessado 2015 nov 11]. Disponível em: http://candido.org.br/unidades-assistenciais/
http://candido.org.br/unidades-assistenc... .

During the 1990s Matrix Support was implemented not only in Campinas but also in other municipalities (Belo Horizonte (in Minas Gerais State), Quixadá (Ceará), Sobral (Ceará), Recife (Pernambuco), Aracaju (Sergipe), and Rio de Janeiro (RJ)).

Starting in 2003, this point of view was incorporated in certain programs of the Health Ministry, such as Humaniza-SUS¹¹11. Brasil. Ministério da Saúde (MS). Secretaria Executiva. Núcleo Técnico da Política Nacional de Humanização. Equipe de referencia e apoio matricial. Brasília: MS; 2004.^,1212. Brasil. Ministério da Saúde (MS). Secretaria Executiva. Núcleo Técnico da Política Nacional de Humanização. Política Nacional de Humanização: documento base para gestores e trabalhadores do SUS. Brasília: MS; 2004., Mental Health¹³13. Brasil. Ministério da Saúde (MS). Saúde Mental e Atenção Básica: o vinculo e o dialogo necessários - inclusão das ações de saúde mental na atenção básica, n°1. Brasília: MS; 2003. and Primary Care¹³13. Brasil. Ministério da Saúde (MS). Saúde Mental e Atenção Básica: o vinculo e o dialogo necessários - inclusão das ações de saúde mental na atenção básica, n°1. Brasília: MS; 2003.. In spite of this, it has only been following the creation of the NASF¹⁴14. Brasil. Ministério da Saúde. Portaria 154, de 24 de janeiro de 2008. Dispõe sobre a criação dos Núcleos de Apoio à Saúde da Família. Diário Oficial da União 2008; 25 jan. that the Health Ministry has made possible the financing that stimulates use of the methodology of Matrix Care in primary healthcare. At present the NASF is regulated by Ministerial Order 2488, of October 21, 2011, and there are 3,057 NASFs implemented in numerous municipalities of the country¹⁵15. Brasil. Departamento de Atenção Básica. Sala de Apoio à Gestão estratégica. [acessado 2015 fev 10]. Disponível em: http://189.28.128.178/sage/
http://189.28.128.178/sage/... .

The experience of Campinas is considered to be a precursor of the Matrix Support strategy. This article aims to share an analysis of the singular experience of this municipality, aiming to contribute to reflections on the challenges of inter-professional work and of the practices related to primary healthcare.

The question that is presented as central in this article is to understand how Matrix Support has been kept incorporated into the practice of professionals, even though it was not a directive of municipal management over the last 10 years. Based on this purpose, the Matrix Support practiced in the SUS of Campinas was investigated from two points of view:

1. identification of the professionals and organizations that use Matrix Support strategy in their daily business; and

2. analysis of the process of the work that is done with the teams that are supported.

Method

This is a descriptive exploratory study, carried out through a questionnaire applied to all the professionals who operate Matrix Support to primary healthcare in Campinas.

It is important to point out that since Matrix Support is not a directive of the current management, there are no official records about the professionals and teams that use this strategy. Due to this, managers of the Health Districts and coordinators of health services were asked for information about services and professionals who it was imagined could be included in the study as Matrix Supporters.

To constitute the population to be investigated, the ‘snowball’ method was used¹⁶16. Turato ER. Tratado da metodologia da pesquisa clínico qualitativa: construção teórico-epistemológica, discussão comparada e aplicação nas áreas da saúde e humanas. Petrópolis: Editora Vozes; 2010., in which the professionals indicated colleagues who also practice Matrix Support. All those indicated were asked to confirm whether or not this condition applied to them: if they answered yes, they were invited to take part in the study.

The population to be investigated was identified as all the professionals who stated they used the Matrix Support strategy as routine; any professionals who, although indicated, said that they did not carry out any Matrix Support action – and/or who refused to take part in the survey – were excluded.

This resulted in a survey universe of 277 professionals who do carry out Matrix Support, in 81 of the 100 services that comprise the Campinas care network. Of this total, 232 (84%) answered the questionnaire.

The questionnaire, prepared by the team of investigators, comprised three types of questions: Open, closed and mixed, grouped by the following themes: General identification, Training, Present position and Matrix Support. A pre-test was carried out in which the instrument was applied to five Matrix Support professionals of Campinas (the first five indicated by the district managers). After this phase the questionnaire was adapted in the following aspects: Language; objectivity and clarity of the questions; and capacity of the questions to meet the objectives proposed by the survey.

Answers were given by the subject filling in the form on their own, monitored by the investigators involved in the study, to answer any questions. The timing of filling in the form was agreed by telephone or email contact. The questionnaires were applied over the period from April 2013 through November 2014.

For this article, only the closed questions have been analyzed. This analysis began with tabulation of the answers, followed by descriptive analysis of the results, carried out on the basis of study of absolute and relative frequencies of the answers, broken down into categories. Microsoft Excel, in the Office 2000 package, was used. The data collected were summarized in tables and distribution charts were derived from them.

After this first analysis, the data were grouped into four categories of analysis:

Category 1 – Identification of the professionals, on the variables: Gender, age, professional category, work location, area of activity of the support professionals.

Category 2 – Work connection with the Campinas SUS, comprising the variables: Employer institution, work links, selection process for entry and contracting of the professionals.

Category 3 – Organization of the work of the Matrix Supporter, through the following information: Entry into the support activities; number of hours per week dedicated to the support activities; composition of the Matrix Support teams; and number of referral teams supported.

Category 4 – Praxis of the support, including the following information: Ways of activating Matrix Support and criteria for discussion of a case with the supporter; tools that are used in Matrix Support actions; evaluation of Matrix Support actions; and supervision.

Ethical aspects

The survey project was approved by the Ethics Committee of the Medical Sciences Faculty of the State University of Campinas. All the participants of the group surveyed signed the Informed Consent Form, authorizing use of the material produced in the survey, with confidentially being conserved.

Results and discussion

The results were organized according to two subject themes with the four categories of analysis defined in the methodology: I) characterization of the professionals that operate with Matrix Support, containing the categories identification of the professional and work link with the Campinas SUS; and; II) practice of Matrix Support, including the following categories: Organization of the Matrix Supporter’s work, and support praxis

Theme I: Characterization of the professionals that operate with Matrix Support

Category 1: Identification of the professionals

Age and gender

Of the 197 professionals who answered the questionnaire, 85% are female, indicating that in the Campinas SUS health work and, in this case, Matrix Support, is a predominantly feminine function.

Age of the population surveyed: No particular age group is predominant. The largest single proportion, 101 professionals (43%), was in the 26 to 35 age group, but there is a further important contingent of 95 professionals (41%) over the age of 41. This indicates that transmission between the ‘generations’ of workers who enter the SUS in different decades is taking place. Such results indicate that young and more experienced professionals are working together, which favors transmission of knowledge and expertise on Matrix Support, even though there have been no training courses in the last 10 years. Part of the sustaining capacity of Matrix Support may be related to the probable propagation of the institutional culture through different ‘generations’ of professionals living and practicing together. A detailed description is shown in Figure 1.

Professional category

In the breakdown by professional category, three groups had the highest frequencies: There were 75 psychologists (32%), 41 occupational therapists (18%) and 35 doctors of differing specialties (15%).

The predominance of psychologists and occupational therapists is coherent with the history of the SUS care network in the municipality of Campinas which, since 1989, has created mental health teams in primary healthcare, aiming to strengthen its capacity for care of less serious mental health problems and to build a new model of mental health care⁵5. Braga Campos FC. O modelo da reforma psiquiátrica brasileira e as modelagens de São Paulo, Campinas e Santos [tese]. Campinas: Universidade Estadual de Campinas; 2000.^,1717. Domitti AC. Um possível diálogo com a teoria a partir das praticas de apoio especializado matricial na atenção básica de saúde [tese]. Campinas: Universidade Estadual de Campinas; 2006.. Subsequently, the professionals involved in the specialized mental health services (CAPS’s) have maintained the practice of contact and discussion of cases with the primary healthcare unit⁵5. Braga Campos FC. O modelo da reforma psiquiátrica brasileira e as modelagens de São Paulo, Campinas e Santos [tese]. Campinas: Universidade Estadual de Campinas; 2000.^, helping to strengthen the arguments for Matrix Support.

The existence of doctors among the most frequent workers in Matrix Support actions is a surprise, even though it represents a small proportion in relation to the total of professionals in this category in the municipality. This information suggests an approximation, by the doctors, to a concept of democratic and interactive work, different from a doctor’s practice as traditionally understood. At the same time, it also shows that in spite of the initial efforts, over the years 2000 to 2004, for implantation of the health policy in the municipality, in which the doctors of the primary network and specialized network were meant to assume the function of supporters, their support is still small in volume if compared to the category of psychologists.

Studies indicate a major difficulty in involving the medical professional in discussions on Matrix Support, for two reasons: excessive burden of work; and difficulty in cancelling the care agenda, since the care model currently in effect is predominantly centered on doctors, giving priority to individual consultations to the detriment of other activities¹⁸18. Minozzo F, Costa II. Apoio matricial em saúde mental entre CAPS e Saúde da Família: trilando caminhos possíveis. Psico-USF Bragança Paulista 2013; 18(1):151-160.^,1919. Pinto AGA, Jorge MSB, Vasconcelos MGF, Sampaio JJC, Lima GP, Bastos VC, Sampaio HA. Apoio matricial como dispositivo do cuidado em saúde mental na atenção primária: olhares múltiplos e dispositivos para resolubilidade. Cien Saude Colet 2012; 17(3):653-660..

Work location and Area where Matrix Support actions are carried out

In the work locations from which professionals carry out Matrix Support actions, described in Table 1, one sees a variety of services, indicating that in spite of the history of Support in Campinas having begun through mental health professionals in primary healthcare, over time this work strategy has expanded, showing that it is possible to use it in various areas of specialized knowledge.

It is seen that the greater the range of specialties involved in dialog with the primary care referral teams through Matrix Support, more varied is the exchange of knowledge, expanding the possibility of these teams offering care based on the assumptions of the Expanded Clinic and integral medicine²⁰20. Campos GWS, Cunha GT, Figueiredo MD. Práxis e formação Paideia: apoio e cogestão em saúde. São Paulo: Editora Hucitec; 2013.. On this aspect, it is important to note that the methodology of Support has been incorporated by other services, as well as those of mental health. However, it also brings to the primary care teams the challenge of coordinating actions and agendas in such a way as to cover these various areas of interaction.

It is worth highlight that most of the professionals who carry out Matrix Support do not do so from the basis of the NASF. This is due to the fact that the management of the Campinas SUS opted not to implement an NASF network. This decision was influenced by the resistance of the professionals themselves, since they were already carrying out Matrix Support by organizing themselves into ‘subject’ groups, of mental health, physical rehabilitation, nutrition, and others. It can be noted that these diversified ways of experiencing Matrix Support are based on the protagonist attitude taken by the professionals, in actively motivating the municipal management over the years 2001 to 2004²¹21. Prefeitura Municipal de Campinas. Secretaria Municipal de Saúde. Programa Paideia: as Diretrizes da Secretaria Municipal de Saúde – Gestão 2001-2004. [acessado 2015 ago 15]. Disponível em: http://www.campinas.sp.gov.br
http://www.campinas.sp.gov.br... , and in their proximity to researchers of the University. Thus, when the NASF was created, in 2008, by the Health Ministry¹⁴14. Brasil. Ministério da Saúde. Portaria 154, de 24 de janeiro de 2008. Dispõe sobre a criação dos Núcleos de Apoio à Saúde da Família. Diário Oficial da União 2008; 25 jan., there were already teams providing Matrix Support to primary healthcare teams, which would appear to explain the diffuse resistance to the implementation of the new instrument recommended by the Health Ministry.

The predominance of services related to the Mental Health area (CAPSs and Convenience Centers) is also evident, when it is considered that 156 professionals (67%) that carry out Matrix Support belong to these activities.

The predominance of Matrix Support in the Mental Health services reaffirms the historic path of implementation of this strategy in the municipality, and reflects the protagonist stance, identified by other studies, taken by the professionals of this area in the construction of new care policies and models, including those of Matrix Support, to favor interaction between the mental health network and primary healthcare³3. Figueiredo MD, Onocko Campos R. Saúde Mental na atenção básica à saúde de Campinas, SP: uma rede ou um emaranhado? Cien Saude Colet 2009; 14(1):129-138.^,1818. Minozzo F, Costa II. Apoio matricial em saúde mental entre CAPS e Saúde da Família: trilando caminhos possíveis. Psico-USF Bragança Paulista 2013; 18(1):151-160.^,1919. Pinto AGA, Jorge MSB, Vasconcelos MGF, Sampaio JJC, Lima GP, Bastos VC, Sampaio HA. Apoio matricial como dispositivo do cuidado em saúde mental na atenção primária: olhares múltiplos e dispositivos para resolubilidade. Cien Saude Colet 2012; 17(3):653-660.^,2222. Azevedo DM, Gondim MCSM, Silva DS. Apoio matricial em saúde mental: percepção de profissionais no território. Rev pesq: cuid fundam online 2013; 5(1):3311-3322.

23. Bonfim IG, Bastos ENE, Góis CWL, Tófoli LF. Apoio matricial em saúde mental na atenção primária à saúde: uma análise da produção científica e documental. Interface (Botucatu) 2013; 17(45):287-300.^-2424. Rosa FM, Weiller TH, François APW, Brites LA, Silveira D, Righi LB. O olhar das equipes de referência sobre o trabalho realizado pelo apoio matricial. Rev Enf UFSM 2011; 1(3):377-385..

Category 2 – Work link with the Campinas SUS

Employer institution

The protagonist stance taken by the Cândido Ferreira service (a philanthropic institution which since 1989 has operated a co-management working agreement with the Campinas Municipal Health Department) in Mental Health and, by extension, in Matrix Support of the municipality, is demonstrated when one looks at the frequency of supporters by employer institution. The figures show that 95 professionals (41%) are contracted by the Cândido Ferreira Health Service, second only to the number contracted by the municipality itself: 128 professionals (55%). The remainder (4%) are contracted by the São Paulo State Association for the Development of Medicine (Associação Paulista para o Desenvolvimento da Medicina), which is a Health Social Organization, responsible, since June 2008, for management of the Mayor Edivaldo Orsi Hospital Complex.

In spite of the co-management nature of the initial agreement between the City Hall of Campinas and the Cândido Ferreira Institute, in an attempt at joint construction of the targets and guidelines for work, the presence of this hospital complex as an employer of professionals who carry out Support coincides with diminishing direct administration by the State, as takes place in the city of São Paulo²⁵25. Silva ATC, Aguiar ME, Winck K, Rodrigues KGW, Sato ME, Grisi AJFE, Brentani A, Rios IC. Núcleos de Apoio à Saúde da Família: desafios e potencialidades na visão dos profissionais da Atenção Primária do Município de São Paulo, Brasil. Cad Saude Publica 2012; 28(11):2076-2084..

Work links

The question of double formal employment was also investigated. Although they were not the majority, 100 professionals (43%) carried out another professional activity outside the municipal health network. Of these, 71 operate in private services, most of them private doctors’ consulting rooms, but also in private hospitals: 19 operate in public hospitals and 10 operate in both public and private institutions.

According to Heimann et al.²⁶26. Heimann LS, Ibanhes LC, Barboza R, organizadores. O público e o privado na saúde. São Paulo: Editora Hucitec; 2005., there is a tension between the Health Reform plan and the plan for public-private partnerships which (re)inaugurated in the 1990s. As a result of this new form of management in the SUS, the relationship that is emerging between public and private is a fragmented model of care, segmented, unequal and oriented by the logic of the productivity of procedures. This situation was found in the organization of Matrix Support, which indicated the need to consider the private sector and its relationship with the SUS in this investigation.

Thus, it can be understood that the fact of people having two jobs may be one of the effects of the influence of the public-private relationship in the daily existence of the SUS. In Campinas, it was observed that the professionals that carry out Matrix Support actions chose the SUS as the priority location for their work. Some of the factors that can justify this choice are: compatible remuneration, presence of an effective jobs and careers plan and a robust care network, with services at all the levels of care, in the public system.

Even not being a majority, one perceives a significant number of professionals who opt to keep a double link. The reasons for this choice are complex and involve several economic, cultural and personal questions, which merit investigation by other methodologies of study.

The process of selection and contracting of professionals

One way of identifying the political project and the decisions of a municipality in Matrix Support is by analysis of the process of selection, and of the work contracts that are offered to professionals. In Campinas, it was possible to find out that there are no specific processes of selection for Matrix Support, and that this theme is not usually required in the selection processes.

A total of 193 professionals (83%) noted that the selection process included questions about public and collective health, but only 74 of them (32%) stated that the process specifically included questions about Matrix Support.

Matrix Support continued to be absent when offering the work contract: 117 professionals (51%) were not informed that the position would include such actions, which suggests that the subject of Support emerged only after they had been allocated and become involved in the work routines. This mismatch could result in several negative situations, such as: not agreeing to this work methodology; professionals resisting reorganization of their agendas to use the matrix tools; and conflicts between professionals and local managers – among other possibilities.

Another point of incoherence was the fact that in the contracting process no prior experience with Matrix Support or Collective Health was called for. In the present survey, 178 professionals (77%) noted that there was no such requirement. However, this would be useful, since the academic training of health professionals is not closely related to the principles of the SUS, and is often insufficient for professionals to act as supporters^{22, 24,27.}

Theme II: Practice of Matrix Support

Category 3 – Organization of the work of the Matrix Supporter

Entry into support activities; number of hours per week dedicated to support activities

According to 153 professionals (66%), the principal way of getting into Matrix Support activities was through an agreement made within the team itself where they work and not a process put into effect by the managers, a priori. This could mean that the organization of the work according to the Support Methodology arises from this work strategy’s penetration among the professionals, and also from the tradition in the SUS of Campinas of seeking to take decisions in a context of co-management. According to Bonfim et al.²³23. Bonfim IG, Bastos ENE, Góis CWL, Tófoli LF. Apoio matricial em saúde mental na atenção primária à saúde: uma análise da produção científica e documental. Interface (Botucatu) 2013; 17(45):287-300., co-management processes are pointed out as factors facilitating adequate implementation of Matrix Support. This could explain why, even with the central management not being disposed to adopt Support as an official guideline, the professionals who work in the municipality still succeed in maintaining a dialog-based practice directed toward democratization of inter-professional relationships.

As for the number of hours dedicated to Matrix Support and its activities in relation to the total of hours for which the person was contracted, there was one item of data causing some concern: the work regimes have periods varying from 12 to 36 hours per week, and the majority work 36 hours/week (108 professionals) or 30 hours/week (86 professionals). In spite of this, 118 (51%) dedicate only 4 hours per week to Support and 46 (20%) dedicate between 5 and 10 hours/week to Support – corresponding to less than 10% of the total weekly workload.

One of the theories to explain this is that, since Matrix Support is not one of the priority guidelines for the organization of the work process in Campinas, professionals who want to work with this methodology need to reconcile their outpatient activities within their specialties with the activities of Support for primary care. Consequently, there may be an interruption of the Matrix Support activities, since these are not guaranteed as continuous duties in the professionals’ routine.

Another hypothesis would be that these figures indicate a restricted concept about Matrix Support on the part of the professionals, and that most of them only counted as time dedicated to Support the team meetings and the educative actions carried out with the teams supported. This would leave out other shared activities, such as individual care sessions, household visits and group activities which, according to Chiaverini²⁸28. Chiaverini DH, organizador. Guia prático de matriciamento em Saúde Mental. Brasília: Centro de Estudo e Pesquisa em Saúde Coletiva; 2011., should quality as activities linked to Support. Thus, it is understood that, in this format, the potential of Support for plasticity/ variability and capacity to resolve problems would be harmed, and run the risk of becoming a bureaucratic action.

Even guaranteeing that Matrix Support is not characterized as an ‘entry portal’, the exclusion of the user of the Matrix Support process contradicts the recommendation proposed by the Health Ministry that actions carried out by the NASF have two principal target publics: the referral teams supported, and the users of the SUS²⁹29. Brasil. Ministério da Saúde (MS). Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Cadernos de Atenção Básica - Núcleo de Apoio a Saúde da Família: ferramentas para a gestão e para o trabalho cotidiano, n° 39. Brasília: MS; 2014..

Composition of the Matrix Support teams and number of referral teams supported

On the components of Matrix Support teams, 145 professionals (62%) reported that they operate in teams with small numbers (an individual person, or two or three professionals). This composition, with few professionals in each team, corresponds to the mode of organization of Matrix Support in Mental Health, which is the prevalent area of Support in the municipality. On the other hand, this strategy of organization with smaller teams and by areas of activity is different from that recommended by the Health Ministry for the NASFs²⁹29. Brasil. Ministério da Saúde (MS). Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Cadernos de Atenção Básica - Núcleo de Apoio a Saúde da Família: ferramentas para a gestão e para o trabalho cotidiano, n° 39. Brasília: MS; 2014..

According to Oliveira³⁰30. Oliveira GN. Apoio Matricial como tecnologia de gestão e articulação em rede. In: Campos GWS, Guerrero AVP, organizadores. Manual de Práticas de Atenção Básica: Saúde Ampliada e Compartilhada. São Paulo: Hucitec; 2008. p. 273-282. the organizational conditions that amplify the possibilities of success and impact of Matrix Support are related to receiving support in a well-defined form, with a clear definition of territorial and populational responsibility of the support teams, and of the services that will be able to rely on the Support. In Campinas, the quantity of primary healthcare teams supported by each professional does not follow a single pattern (Figure 2), and shows an organization that is heterogeneous in the attribution of services/teams that will be supported.

The majority of professionals (69%) stated that they support less than 9 referral teams, and this is aligned with the official discourse of the Health Ministry in its recommendation about the activity of the NASF²⁹29. Brasil. Ministério da Saúde (MS). Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Cadernos de Atenção Básica - Núcleo de Apoio a Saúde da Família: ferramentas para a gestão e para o trabalho cotidiano, n° 39. Brasília: MS; 2014..

However, 30 professionals (13%) stated that they support the whole of the network of a Health District (each district has at least 10 and a maximum of 30 primary healthcare units), and 12 professionals (5%) reported that they offer support to more than one health district. These data merit attention, since according to Hirdes³¹31. Hirdes A. A perspectiva dos profissionais da Atenção Primária à Saúde sobre o apoio matricial em saúde mental. Cien Saude Colet 2015; 20(2):371-382. there are professional principles such as inter-disciplinarity, the employment relationship, integrality of care, capacity to resolve problems, accessibility and longitudinally that gives sustainability to Matrix Support practices, and that supporting an excessive quantity of teams can harm the institution of those principles and the effective implementation of the Support.

Category 4: Support praxis

Ways of activating Matrix Support; criteria for discussion of the case with the Supporter

Two ways are recommended for establishing contact between referrals and supporters: (i) through scheduling of periodic and regular meetings in which clinical cases selected by the health team would be discussed; and (ii) support for unforeseen and urgent cases that cannot wait for the regular meeting²2. Campos GWS, Domitti AC. Apoio matricial e equipe de referência: uma metodologia para gestão do trabalho interdisciplinar em saúde. Cad Saude Publica 2007; 23(2):399-407..

In the municipality of Campinas, the principal forms of activating support, on general lines, follow the steps described above. 79 professionals (34%) stated that the support agenda is built through a pact between a Matrix Support Team and a Referral Team supported, and also includes the possibility of the teams supported requesting occasional support. It is also observed that the construction of the agenda is influenced by several instances, involving the supported referral team, the Support team, and also as mentioned by some respondents, participation of the local management in this pact, in various arrangements as described in Table 2.

As well as the ways of activating Matrix Support, it is equally important to consider the definition of directives of risk and of access to the supporting specialists³3. Figueiredo MD, Onocko Campos R. Saúde Mental na atenção básica à saúde de Campinas, SP: uma rede ou um emaranhado? Cien Saude Colet 2009; 14(1):129-138..

However, it was found that only 129 professionals (56%) indicated the existence of criteria for selection of the cases that demand discussion with Matrix Support. Of these, 90 said that these are constructed in a shared manner, between the Support team and the Referral team; 32 said that the construction involves the Matrix Support team and the local management; 44 stated that they were constructed by the referral team independently; 10 professionals believed that they were constructed by the supporters alone, 12 state that it was the independent management that constructed the criteria; and only 6 were unable to say how the criteria were constructed.

The non-existence of criteria for selection of the cases for Matrix Support indicates that the problems and cases to be supported are defined at the moment of the discussion or through contracts generated between the professionals themselves. However, this pattern of indefinition of the role of Support, combined with the high number of professionals who offer Support to too many teams, harms the territorialization and the employment link, and, due to the low number of hours of work per week dedicated to Support, it would appear to be of fundamental importance to construct criteria to guide the actions of the people providing Support.

Tools that are used in Matrix Support actions

The Figure 3 shows the principal tools used by Matrix Support professionals.

The figure indicates that the Matrix Support professionals make use of various tools, including almost the totality of the instruments recommended by the guidelines of the NASF³²32. Brasil. Ministério da Saúde (MS). Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Cadernos de Atenção Básica - Diretrizes do NASF: Núcleo de Apoio a Saúde da Família, n°27. Brasília: MS; 2009., HumanizaSus – the reference team and Matrix Support¹⁰10. Serviço de Saúde Dr. Candido Ferreira. Unidades Assistenciais. [acessado 2015 nov 11]. Disponível em: http://candido.org.br/unidades-assistenciais/
http://candido.org.br/unidades-assistenc... and practical guide to Matrix Support in mental health²⁸28. Chiaverini DH, organizador. Guia prático de matriciamento em Saúde Mental. Brasília: Centro de Estudo e Pesquisa em Saúde Coletiva; 2011., with an exception only for the construction of the genogram and the Eco-map which did not appear in the responses. It is important to remember that, the greater the diversity of offers by the Supporters, the more capable of resolution do the actions taken in support of primary healthcare tend to be, helping to reduce the resistances of the Referral Team in relation to this type of methodology²2. Campos GWS, Domitti AC. Apoio matricial e equipe de referência: uma metodologia para gestão do trabalho interdisciplinar em saúde. Cad Saude Publica 2007; 23(2):399-407..

However, it is curious to note that direct assistance to users was marked as a support tool, but was not considered as such when the respondents were calculating the number of hours they dedicated to Support, which underlines the need for qualitative investigations on this question. It would also be recommendable to investigate in what way these tools are used: Whether they maintain the character of dialog and the logic of co-responsibility proposed by Matrix Support, or whether they are carried out in a fragmented and merely bureaucratic manner¹⁹19. Pinto AGA, Jorge MSB, Vasconcelos MGF, Sampaio JJC, Lima GP, Bastos VC, Sampaio HA. Apoio matricial como dispositivo do cuidado em saúde mental na atenção primária: olhares múltiplos e dispositivos para resolubilidade. Cien Saude Colet 2012; 17(3):653-660..

Evaluation of the actions of Matrix Support and supervision

Finally, to understand the possibility of maintenance of the culture of realization of Matrix Support, it is important to check the existence of assessment of the actions taken, and also of the regular spaces of clinical-institutional supervision of these professionals, which would serve as means for disclosure of the assumptions inherent in this method of work.

However, according to 157 professionals (68%), there is no formal or informal assessment of the activities of Matrix Support carried out in Campinas. It was also found that 179 professionals (77%) did not receive supervision or another type of support to strengthen their actions.

This absence must be overcome in order to enable the analysis of the Matrix Support and feedback of its potential to transform the hegemonic practices³3. Figueiredo MD, Onocko Campos R. Saúde Mental na atenção básica à saúde de Campinas, SP: uma rede ou um emaranhado? Cien Saude Colet 2009; 14(1):129-138..

Arona³³33. Arona EC. Implantação do matriciamento nos serviços de saúde de Capivari. Saúde Soc 2009; 18(Supl. 1):26-36. highlights the importance of creation of forms of assessment of the activities in a participative manner, based on co-management, to make progress in the consolidation of Matrix Support. Further, such spaces could become a powerful means for ensuring the training of Supporters. For training does not mean political point models and / or pedagogical ideal, abstract and dissociated from the work process, but raise reflections on the daily work with the teams and users. In the surveillance space, which allows the participation of outside analysts, it is possible to reflect on practice, anxieties, tensions and other emerging issues in everyday²2. Campos GWS, Domitti AC. Apoio matricial e equipe de referência: uma metodologia para gestão do trabalho interdisciplinar em saúde. Cad Saude Publica 2007; 23(2):399-407..

Final considerations

This article has presented the maintenance of Matrix Support in Campinas as a central issue – Campinas is a pioneer municipality in the use of this work methodology. In this aspect, more than evaluating the Support practices, its aim was to characterize the way in which they have been developed up to the present day.

This enquiry has shown that Matrix Support takes place in a very heterogeneous range of ways in the municipality, but that, 20 years after its implementation, it has achieved an important degree of consolidation.

The survival of Matrix Support, in spite of the municipal management not having adopted it as a government guideline for organization of health work, whether in the form of subject teams, or in the NASF modality, during the last 10 years, needs to be highlighted.

To continue to cultivate Matrix Support as an element of the institutional culture, in spite of these political difficulties, it to emphasize the protagonist role taken by the professionals involved. The fact that 232 of them state themselves to be supporters identifies an almost unilateral belief on their part in the usefulness and potential of Matrix Support, and confirms the existence of a determined conviction that this methodology helps to strengthen the integrative character of the healthcare provided, and the capacity of both primary healthcare and the SUS to resolve problems.

It was observed that Campinas is different from the other municipalities and from the ministerial NASF proposals¹³13. Brasil. Ministério da Saúde (MS). Saúde Mental e Atenção Básica: o vinculo e o dialogo necessários - inclusão das ações de saúde mental na atenção básica, n°1. Brasília: MS; 2003., due to the variety of professional categories and work locations from which Matrix Support is carried out. Although this diversity points to progressive inclusion of other specialties, expanding the possibilities of use of Support to other contexts, the survey revealed that the concentration of activities of Support is maintained in the area of Mental Health which, historically, in the municipality, was the pioneer in realization of what could be called the prototype of Support.

Based on the experience reported in this article it becomes possible to list some strong points of Support which can help in the implementation and consolidation of the practice in other municipalities: flexibility for the composition of the support teams which go outside the format of the NASF and are able to be organized as subject teams compatible with the needs of the territory; guarantee of the number of working hours for continuous Matrix Support actions; shared construction of the work guidelines; use of multiple tools in the contact with the supported teams and users; and ensuring that there are spaces for reflection on the practice and assessment of the activities.

However, the study points to certain fragile aspects which merit attention to avoid their making the use of the methodology unfeasible: the low number of working hours dedicated to Support; and the high number of teams supported by each Support team.

Finally, this study shows the need for further surveys, of a qualitative nature, about the activities of direct assistance to users, and about processes of assessment that would involve managers, professionals and users. The construction of this type of knowledge tends to strengthen implementation and consolidation of Matrix Support, not only in Campinas but in the whole of Brazil.

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