Abstract

This paper aims to analyze the profile and perceptions of the municipal health secretaries on the agendas and challenges for the SUS in the 2017-2020 cycle, with emphasis on the participation of nurses in management. The data were collected through an online electronic questionnaire, containing closed-ended questions, answered by municipal managers, within the National Survey of Municipal Health Secretaries, a national study carried out in 26 states in 2017 and 2018. We could understand to what extent nurse managers perceive the main challenges, the performance of strategic actors, the dynamics of interagency spaces, and federative agendas necessary to strengthen SUS management in the management process.

Key words
Health management; Unified Health System; Nurse

Introduction

Inspired by values such as equality, democracy and emancipation, the Unified Health System (SUS) is part of the Brazilian Federal Constitution, ordinary legislation and technical and administrative standards, with a network of educational and research institutions such as universities, public health institutes and schools interacting with state and municipal secretariats, the Ministry of Health, agencies and foundations, contributing to their institutional sustainability, enabling a group of people to acquire knowledge, skills and values linked to their principles and guidelines¹1 Paim JS. Sistema Único de Saúde (SUS) aos 30 anos. Cien Saude Colet 2018; 23(6):1723-1728. [acessado 2019 Abr 08]. Disponível em: http://www.scielo.br/pdf/csc/v23n6/1413-8123-csc-23-06-1723.pdf
http://www.scielo.br/pdf/csc/v23n6/1413-... .

According to Paim¹1 Paim JS. Sistema Único de Saúde (SUS) aos 30 anos. Cien Saude Colet 2018; 23(6):1723-1728. [acessado 2019 Abr 08]. Disponível em: http://www.scielo.br/pdf/csc/v23n6/1413-8123-csc-23-06-1723.pdf
http://www.scielo.br/pdf/csc/v23n6/1413-... , creative political and institutional engineering allowed developing basic operating standards, agreement, integrated agreed programming, regionalization development plan and investment master plan that contributed to institutional sustainability of the SUS and its materiality expressed in establishments, teams, equipment and technologies, besides the construction of historical alliances that resulted in the formation of the Brazilian Health Reform Movement (MRSB).

Thus, as we celebrate the 30^th anniversary of the SUS, it should be noted that its implementation requires a society in which all citizens have ensured a decent standard of living. Indeed, SUS is one of the essential strategies for building a socially fair country, but despite significant advances since the early 1990s, the possible SUS is still far from the necessary SUS²2 Souza LEPF. O SUS necessário e o SUS possível: estratégias de gestão. Uma reflexão a partir de uma experiência concreta. Cien Saude Colet 2009; 14(3):901-918. [acessado 2019 Abr 08]. Disponível em: http://www.scielo.br/pdf/csc/v14n3/27.pdf
http://www.scielo.br/pdf/csc/v14n3/27.pd... .

In this context, we can highlight that, as a federative policy, the SUS institutionalization process is gradually establishing the new competencies and governmental responsibilities, which amid conceptual, logistical, technological and instrumental innovations, daily influence the exercise of sectoral management, often under different, diverse and plural conditions³3 Carvalho ALB, Souza MF, Shimizu HE, Senra IMVB, Oliveira KC. A gestão do SUS e as práticas de monitoramento e avaliação: possibilidades e desafios para a construção de uma agenda estratégica. Cien Saude Colet 2012; 17(4):901-911..

In the wake of this discussion, it should be emphasized that, besides the development of a whole logistics and regulatory technology based on priority needs, vulnerabilities, and risks, we require political mediation and definition of guidelines and criteria from the spaces of participation and social control¹1 Paim JS. Sistema Único de Saúde (SUS) aos 30 anos. Cien Saude Colet 2018; 23(6):1723-1728. [acessado 2019 Abr 08]. Disponível em: http://www.scielo.br/pdf/csc/v23n6/1413-8123-csc-23-06-1723.pdf
http://www.scielo.br/pdf/csc/v23n6/1413-... .

Although the Constitution guarantees “health as a right of all and the duty of the State”, the Brazilian State, through the Executive, Legislative, and Judiciary, has not yet ensured the objective conditions for economic and scientific and technological sustainability of the SUS. Management problems such as lack of professionalization, clientelist and partisan use of public establishments, an excessive number of positions of trust, bureaucratization of decisions, and administrative discontinuity have been highlighted, although the alternatives triggered imply the devaluation of workers through outsourcing and job insecurity¹1 Paim JS. Sistema Único de Saúde (SUS) aos 30 anos. Cien Saude Colet 2018; 23(6):1723-1728. [acessado 2019 Abr 08]. Disponível em: http://www.scielo.br/pdf/csc/v23n6/1413-8123-csc-23-06-1723.pdf
http://www.scielo.br/pdf/csc/v23n6/1413-... .

Paim and Teixeira⁴4 Paim JS, Teixeira CF. Política, planejamento e gestão em saúde: balanço do estado da arte. Rev Saude Publica 2006; 40(n. esp.):73-78. highlight among the various critical nodes related to the (organizational structure) design and the SUS management process, the lack of clarity, and insufficient consensus around the SUS “Image-Objective”, which maintains the rhetoric of the “SUS we want”, and leads to the dissension of the roles and competencies of the various spheres of government, reproduced among the various spheres – federal, state, and municipal – and in each of them.

In this context, we can consider that SUS management cycles occur in a political-institutional scenario in which the problem of the organization and management of the health system is extremely dynamic, considering the decentralization-municipalization process, but also by the change in the correlation of forces in the Interagency Commissions, Health Councils and collegiate representative of managers, namely: National Council of State Secretaries (CONASS) and Council of Municipal Health Secretariats (CONASEMS).

Paim¹1 Paim JS. Sistema Único de Saúde (SUS) aos 30 anos. Cien Saude Colet 2018; 23(6):1723-1728. [acessado 2019 Abr 08]. Disponível em: http://www.scielo.br/pdf/csc/v23n6/1413-8123-csc-23-06-1723.pdf
http://www.scielo.br/pdf/csc/v23n6/1413-... states that the leadership of CONASS and CONASEMS since the nineties, together with the installation of state and municipal councils, has allowed the expansion of the SUS foundation block. Thus, the practices of municipal health managers have reinforced these social and political bases, and this paper seeks to present their analyzed profile for the 2017-2022 cycle, with an emphasis on the main challenges and agendas required to strengthen the SUS.

Management practices and the incorporation of nursing professionals

Campos⁵5 Campos GWS. O público, o estatal, o privado e o particular nas políticas públicas de saúde. In: Heimann LS, Ibanhes LC, Barbosa R, organizadores. O público e o privado na saúde. São Paulo: Hucitec; 2005. p. 89-110. argues that management requires respect for rationality, but must act creatively without repeating guidelines, rules, or acts. It should drive innovation, dynamism, and leadership while remembering legal obligations on budgets, rights, and duties, representations of the different social actors interested in that service.

Management involves improving the functioning of organizations and, to this end, has to find the best possible combination of resources available to achieve its goals. Once this combination is found, it is institutionalized through the formalization of structures, processes, routines, flows, and procedures⁶6 Magalhães AMM, Riboldi CO, Dall'Agnol CM. Planejamento de recursos humanos de enfermagem: desafio para as lideranças. Rev Bras Enferm 2009; 62(4):608-612..

It is evident that, besides the technical capacity, the ethical and political commitment of technicians and managers, it is necessary to invest in processes that allow the adoption of measures that expand the possibilities of intervention in inappropriate situations, reducing inequalities identified by the management regarding the citizen's life and health condition.

The role of management in health, at any institutional level, identifies several challenges that must be addressed. Managers face different situations and issues that can be tackled differently, depending on combinations of techniques/methods and technologies/equipment available for organizing work processes, plus a wide variety of items and resources they will have to deal with in their daily routine⁷7 Brasil. Ministério da Saúde (MS). Portal de Saúde - SUS [Internet]. [acessado 2019 Jun 12]. Disponível em: http://portalsaude.saude.gov.br
http://portalsaude.saude.gov.br... .

The presence of nurses acting as managers is becoming a frequent practice in Brazil, which corroborates the norms inherent to managerial practice, especially Decree N° 94.406/8, article 8, which establishes that this professional is assigned the duties of direction and management, planning, organization, coordination and evaluation of nursing services, as well as the National Curriculum Guidelines of Undergraduate Nursing Courses – Opinion No. CNE/CES 1.133/2001, where we find some specific skills of the profession, which concern managerial responsibilities⁸8 Silva FHC. A Atuação dos Enfermeiros como Gestores em Unidade Básicas de Saúde. Revista de Gestão em Sistemas de Saúde - RGSS 2012; 1(1):67-82.

9 Brasil. Decreto nº 94.406, de 8 de junho de 1987. Regulamenta a Lei nº 7.498 de 25 de junho de 1986, que dispõe sobre o exercício da enfermagem e dá outras providências. Diário Oficial da União 1987; 9 jun.^-1010 Brasil. Ministério da Educação. Conselho Nacional de Educação. Parecer CNE/CES nº. 1.133/2001. Diretrizes Curriculares Nacionais dos Cursos de Graduação em Enfermagem, Medicina e Nutrição. Diário Oficial da União 2001; 3 out..

Nascimento and Nascimento¹¹11 Nascimento MS, Nascimento MAA. A prática da enfermeira no Programa de Saúde da Família: a interface da vigilância da saúde versus as ações programáticas em saúde. Cien Saude Colet 2005; 10(2):333-345. say that nursing is a profession with significant contingent of professionals working in various places and developing the most diverse functions within the health area, and their practice has been undergoing some transformations, shifting their professional practice from the curative, individualized, hospital institution-linked area, to the production of services in Primary Care Facilities, with emphasis on community-based health promotion and protection actions.

Thus, the issues that involve nurses in health management are increasingly present in the daily lives of managers, professionals, and researchers. However, in the training of nurses, we observe little attention in preparing them to undertake technical administrative, and care functions, where the nursing professional inserted in the macro or microstructural plan acts as an agent that contributes to the management of the municipal SUS¹²12 Bernardes A, Cecílio LCO, Nakao JRS, Évora YDM. Os ruídos encontrados na construção de um modelo democrático e participativo de gestão hospitalar. Cien Saude Colet 2007 [acessado 2019 Maio 12]; 12(4):861-870. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1413-81232007000400008
http://www.scielo.br/scielo.php?script=s...

13 Souza MKB, Melo CMM. Perspectiva de Enfermeiras gestoras acerca da gestão municipal. Rev Enferm UERJ 2009; 17(2):198-202.^-1414 Fonseca MGM. Mulheres e poder na saúde: estudo de enfermeiras secretárias municipais de saúde no estado da Bahia [dissertação]. Salvador: Universidade Federal da Bahia; 2001..

A set of studies confirms the prominent participation of nursing in the organization and accountability in administrative processes, in the development of management practices in the UBS, or even in the expanded field of nursing, especially in the occupation of leadership and direction positions of the local SUS, a situation that has been shaping up since the 1990s, and can be verified by the survey made by CONASEMS, in the 1997-2000 period in the municipalities of the State of Bahia, which evidenced that in 60 of them, 55% were nurses. This was repeated for the 2013-2016 management cycle, where health professionals, especially nursing (32.7%)¹⁵15 Dantas TCCD. A prática gerencial de enfermeiras em unidades básicas de saúde [dissertação]. Salvador: Universidade Federal da Bahia; 2000.^,1616 Carvalho LBC. Perfil dos Gestores Municipais de Saúde - Ciclo 2013 a 2016: Informe Técnico. Brasília: CONASEMS, UFPB, Fiocruz-CEE; 2016. prevailed in the 723 (13%) municipalities that responded.

Thus, it is evident that nursing, among the various health professions, has assumed positions of direction and management, which requires from the nurse leadership skills such as flexibility, ability to discern the needs of the people supervised, and mainly the motivation of employees, making the most of their skills without exploiting them¹⁷17 Pereira LA, Primo LS, Tomaschewski-Barlem JG, Barlem ELD, Ramos AM, Hirsh. CD. Enfermagem e liderança: percepções de enfermeiros gestores de um hospital do sul do Brasil. Rev pesqui cuid fundam online. 2015: Jan-Mar [acessado 2019 Maio 12]. 7(1):1875-1882. Disponível em: http://www.seer.unirio.br/index.php/cuidadofundamental/article/view/3545/pdf_1421
http://www.seer.unirio.br/index.php/cuid...

18 Ruthes RM, Icko C. Contribuições para o conhecimento em gerenciamento de enfermagem sobre gestão por competência. Rev gaúcha enferm [Internet]. 2007 Dec. [acessado 2019 Maio 12]; 28(4):570-575. Disponível em: http://www.seer.ufrgs.br/RevistaGauchadeEnfermagem/article/viewFile/3154/1727
http://www.seer.ufrgs.br/RevistaGauchade... ^-1919 Ribeiro JM, Moreira MR, Ouverney AM, Pinto LF, Silva CMFP. Federalismo e políticas de saúde no Brasil: características institucionais e desigualdades regionais. Cien Saude Colet 2018; 23(6):1777-1789..

It is worth noting that SUS managers have to formulate and implement different strategies to conduct management processes in a complex context, characterized both by increased service offerings, expansion and diversification of policies and programs, institutionality gains and improved regional governance levels, as well as the persistent, significant regional disparities, low coordination and planning capacity, distributive conflicts, insufficient funding, judicialization and absence of relevant system actors²⁰20 Lima LD, Viana ALA, Machado CV, Albuquerque MV, Oliveira RG, Iozzi FL, Scatena JHG, Mello GA, Pereira AMM, Coelho APS. Regionalização e acesso à saúde nos estados brasileiros: condicionantes históricos e político-institucionais. Cien Saude Colet 2012 Nov [acessado 2019 Jun 15]; 17(11):2881-2892. Disponível em: http://www.scielo.br/pdf/csc/v17n11/v17n11a04.pdf
http://www.scielo.br/pdf/csc/v17n11/v17n...

21 Moreira MR, Ribeiro JM, Ouverney AM. Obstáculos políticos à regionalização do SUS: percepções dos secretários municipais de Saúde com assento nas Comissões Intergestores Bipartites. Cien Saude Colet 2017 Abr [acessado 2019 Maio 12]; 22 (4):1097-1108. Disponível em: http://www.scielo.br/pdf/csc/v22n4/1413-8123-csc-22-04-1097.pdf
http://www.scielo.br/pdf/csc/v22n4/1413-...

22 Machado CV, Lima LD, Viana ALA, Oliveira RG, Iozzi FL, Albuquerque MV, Scatena JHG, Mello GA, Pereira AMM, Coelho APS. Federalismo e política de saúde: comissões intergovernamentais no Brasil. Rev Saude Publica 2014; 48(4):642-650.

23 Vermelho SC, Figueiredo GA. A percepção dos secretários municipais de saúde sobre a gestão do trabalho e da educação na rede pública do Sistema Único de Saúde (SUS). Saude Soc 2017; 26(2):382-396.^-2424 Andrade NA, Lanza LMB. A percepção de gestores municipais de saúde em relação ao enfrentamento à mortalidade infantil em territórios da 22ª regional de saúde do Paraná: elementos que antecedem a PEC dos 20 anos. Humanidades & Inovação. 2018; 5(11):127-140. In: IV Encontro de Gestão de Pessoas e Relações de Trabalho; 2013 nov 3-5; Brasília: Associação Nacional de Pós-Graduação e Pesquisa em Administração - ANPAD.. Thus, we can affirm that the change of SUS management cycles must be studied and analyzed systematically. One way of doing this is through the characterization and analysis of the profile of the new municipal managers and their perception of the processes of management and participation within the SUS.

In this context, this study becomes relevant, due to the need to understand the profile and perception of nurse managers about their challenges and strategic agendas as they assume the role of municipal health secretaries in the 2017-2020 cycle.

Research methods

Research design

This paper builds on data collected in the National Survey of SUS Municipal Managers, developed from the partnership between CONASEMS, the Department of Social Sciences of ENSP/Fiocruz, and the Department of Health Promotion/UFPB, with the objective of analyzing the profile and perceptions of municipal health secretaries about the agendas and challenges for the SUS for the 2017-2020 cycle. Regarding the profile of managers and the characterization of managers' perceptions, the study covered the following realms:

Socioeconomic background, personal and occupational characteristics, professional and political path, public life, and aspects related to the position of municipal health secretary, including the reasons for the appointment and the motivations to assume the position.

The relevance of interagency agreement and social control spaces and levels (CIT, CIB, and CIR; CNS, CES, and CMS).

The current situation, challenges, and perspectives of SUS strategic policies, especially Primary Care, Medium and High Complexity Care; Regionalization and Management, Planning; Social Control, Judicialization; Work Management, and Financing.

Influence of actors and entities on local health policy management processes and practices.

Interagency priority agendas – main movements of state managers, the Ministry of Health, and CONASEMS in the construction of strategic agendas for the 2017-2020 cycle.

The realms highlighted above are related to the scope defined in previous research on the subject, which added to the inputs from interviews and meetings with members of CONASEMS management and former municipal health managers²⁵25 Martins MD, Costa CF. Gestão por Competências: O Perfil dos Secretários Municipais de Saúde do Estado do Rio Grande do Sul 2012. [acessado 2019 Maio 15] Disponível em: http://www.anpad.org.br/admin/pdf/EnGPR130.pdf
http://www.anpad.org.br/admin/pdf/EnGPR1...

26 Arruda CAM, Pessoa VM, Barreto ICHC, Carneiro FF, Comes Y, Trindade JS, Silva DD, Santos LMP. Perceptions of city health managers about the provision and activity of physicians from the More Doctors Program. Interface (Botucatu) 2017; 21(Supl.1):1269-^-2727 Fleury S, Mafort OA, Molle RC. Democratização do Poder Local e as imensões da Inovação em Saúde: desafios metodológicos da investigação. In: Fleury S, Mafort OA, Molle RC. Democracia e inovação na gestão local da saúde. Rio de Janeiro: Cebes/Editora Fiocruz; 2014. p. 121-199.. These realms were broken down into variables, for which 57 questions were prepared, programmed in the virtual platform Survey Monkey²⁸28 Survey Monkey. [acessado 2019 Abr 03]. Disponível em: https://pt.surveymonkey.com/
https://pt.surveymonkey.com/... , and previously tested with 300 managers in July 2017, during the XXIII CONASEMS National Congress.

Data collection

A web-based questionnaire was made available to all local managers, and a technical follow-up group linked to the group of 200 local supporters of these councils was organized to expedite work. The links to access the questionnaire were open from July 2017 to August 2018, with a record of 3,899 respondents (70%) of the 5,570 municipal health secretaries. Of these, 2,313 (59.3%) answered the questionnaire in full, and this was the base we adopted to analyze this paper. Finally, we highlight that all municipal health secretaries who participated in the research allowed the use of data in scientific publications through the Informed Consent Form (ICF), which was linked to the electronic questionnaire.

Data systematization

Concerning data analysis, the completed questionnaires were extracted into a Microsoft Excel database, organized by respondents (municipality), health region, federation unit, and region.

Results and discussion

Profile and path

Concerning profiles, based on the data shown in Table 1, we can state that SUS municipal managers are mostly female (58%), aged between 31 and 50 years (67%), white (59%), with higher education (81%) and postgraduate studies (49%). Regarding the situation of other managers and nurse managers concerning gender, age, and schooling, values presented by the nurses are higher than those of other managers, especially schooling, which is 99% for higher education and 75% for postgraduate studies.

Concerning the professional path, nursing predominates (26%) among SUS female managers, with a characteristic that they have never assumed the role of health secretaries (59%), but had previous experience coordinating Primary Care (54%).

As for the motivation to assume managerial roles, we highlight strengthening the SUS (80%), and this motivation was more prominent concerning nurse managers (85%); serving the city (76%), with minimal difference between other managers (77%) and nurse managers (75%), and taking on new challenges (71%), where again nurse managers stand out in their statements (75%).

In the approach taken on the possible positive points for his appointment, personal trust (64%) is highlighted, followed by capacity and leadership and technical competence (59%); except personal trust attribute, nurse managers have higher percentages than the other managers, with emphasis on motivation and technical competence (69%). Complementarily, two attributes stand out, which relate to the ability to dialogue (34%) and to mobilize (24%), with higher proportion of the ability to mobilize (31%) among nurse managers.

Thus, we can state that the profile of SUS managers reveals a leadership by women, white, over 40 years of age, with higher education and postgraduate studies, linked to the nursing course, from primary and secondary care. Most of them had no previous experience as municipal managers, and said they took office to strengthen the SUS, facing challenges and serving their city, with the mayor's trust as a driving force and having specific attributes such as leadership, ability to dialogue and mobilize and technical competence.

The results confirm the participation of nursing in the organization and accountability in administrative processes, and particularly in the management practices in primary care facilities, especially holding leadership positions, something that is in line with the studies conducted by CONASEMS on the participation of women who held the position of municipal secretary¹⁷17 Pereira LA, Primo LS, Tomaschewski-Barlem JG, Barlem ELD, Ramos AM, Hirsh. CD. Enfermagem e liderança: percepções de enfermeiros gestores de um hospital do sul do Brasil. Rev pesqui cuid fundam online. 2015: Jan-Mar [acessado 2019 Maio 12]. 7(1):1875-1882. Disponível em: http://www.seer.unirio.br/index.php/cuidadofundamental/article/view/3545/pdf_1421
http://www.seer.unirio.br/index.php/cuid... ^,1818 Ruthes RM, Icko C. Contribuições para o conhecimento em gerenciamento de enfermagem sobre gestão por competência. Rev gaúcha enferm [Internet]. 2007 Dec. [acessado 2019 Maio 12]; 28(4):570-575. Disponível em: http://www.seer.ufrgs.br/RevistaGauchadeEnfermagem/article/viewFile/3154/1727
http://www.seer.ufrgs.br/RevistaGauchade... ^,2020 Lima LD, Viana ALA, Machado CV, Albuquerque MV, Oliveira RG, Iozzi FL, Scatena JHG, Mello GA, Pereira AMM, Coelho APS. Regionalização e acesso à saúde nos estados brasileiros: condicionantes históricos e político-institucionais. Cien Saude Colet 2012 Nov [acessado 2019 Jun 15]; 17(11):2881-2892. Disponível em: http://www.scielo.br/pdf/csc/v17n11/v17n11a04.pdf
http://www.scielo.br/pdf/csc/v17n11/v17n... ^,2121 Moreira MR, Ribeiro JM, Ouverney AM. Obstáculos políticos à regionalização do SUS: percepções dos secretários municipais de Saúde com assento nas Comissões Intergestores Bipartites. Cien Saude Colet 2017 Abr [acessado 2019 Maio 12]; 22 (4):1097-1108. Disponível em: http://www.scielo.br/pdf/csc/v22n4/1413-8123-csc-22-04-1097.pdf
http://www.scielo.br/pdf/csc/v22n4/1413-... .

The findings are in agreement with other studies, where it is evident that nursing has been assuming management positions and had to exercise the roles of leadership, flexibility, ability to discern health needs²⁰20 Lima LD, Viana ALA, Machado CV, Albuquerque MV, Oliveira RG, Iozzi FL, Scatena JHG, Mello GA, Pereira AMM, Coelho APS. Regionalização e acesso à saúde nos estados brasileiros: condicionantes históricos e político-institucionais. Cien Saude Colet 2012 Nov [acessado 2019 Jun 15]; 17(11):2881-2892. Disponível em: http://www.scielo.br/pdf/csc/v17n11/v17n11a04.pdf
http://www.scielo.br/pdf/csc/v17n11/v17n... ^,2121 Moreira MR, Ribeiro JM, Ouverney AM. Obstáculos políticos à regionalização do SUS: percepções dos secretários municipais de Saúde com assento nas Comissões Intergestores Bipartites. Cien Saude Colet 2017 Abr [acessado 2019 Maio 12]; 22 (4):1097-1108. Disponível em: http://www.scielo.br/pdf/csc/v22n4/1413-8123-csc-22-04-1097.pdf
http://www.scielo.br/pdf/csc/v22n4/1413-... .

Decision-making process, actors and strategic situations

Concerning decision-making, we identified the influence of the Mayor, followed by the Health Council and the Ministry of Health (MS). This sequence does not differ across the set of managers, and concerning the Mayor, nurse managers have a higher proportion.

When analyzing the level of this influence, we find that the percentages inherent to the three actors are significantly higher for nurse managers in the North and Midwest regions. Data reveal the predominance of three actors, with variations, and bring data of concern, namely, the absence of the state manager in the decision-making scenario (Table 2).

Regarding the decision-making situations, we highlight agendas linked to the Municipal Health Council (CMS); Regional Interagency Commission (CIR), and the Audit Reports. The sequence does not differ between managers, agendas with the Health Council are predominant, and nurse managers have the highest percentages.

Analyzing the level of influence, we found that the Council Agenda is predominant for both, with emphasis on the other managers in the North, South, and Southeast. However, for the other agendas, the percentages shown by nurse managers are higher, highlighting the Northeast and Midwest regions, where the predominance for the three situations is significant.

Main challenges of SUS management

The research explored eight axes, as shown in Chart 1. In general, the highlighted challenges are common when we verify the situation in Brazil. Worth noting are the counterpart of the State (50%) in Primary Care, ensuring quantity and quality of appointments, exams, and hospitalizations (71%) in Specialized Care, as a priority; regarding Regionalization, the strengthening of CIRs as regional planning and agreement bodies (56%). As for the planning process, the qualification of local management teams for health planning practice was underscored (66%).

Concerning Social Control, the need for supporting the process of training health counselors (43%) stood out as a national agenda. As for Judicialization, the need to expand the knowledge of the control bodies on the dynamics of management within the SUS (64%), the implementation and agreement of guidelines for education and work management policies that favor the provision and establishment of health workers at the municipal level (52%) stood out as the main challenge in the work management and health education axis, and finally, the guarantee of stable and sustainable funding for the SUS, improving the standard of spending and qualifying tripartite funding (68%) nationwide.

Observing the set of axes, we can verify that nurse managers show higher percentages than the other administrations and the whole country concerning Primary Care, Regionalization, Social Control, and Judicialization.

Regarding the Planning and Work Management realms, while challenges are the same, percentages do not differ, as is the case of Financing for nurse managers and other managers. The only realm where nurse managers have lower percentages is in Specialized Care.

The Specialized Care realm stands out as the one that had the challenge as the highest percentage, followed by Financing, Planning, Judicialization, Regionalization, Work Management, Primary Care, and finally, Social Control.

Priority federative agendas for the 2017-2020 cycle

The results of Chart 2 show the position of managers concerning the priority agendas for the 2017-2020 period. Concerning the Ministry of Health, the following stand out: increasing financial support for strategic programs aimed at improving people's access (73%), broaden support to primary care and health surveillance actions aimed at strengthening health system's gateway actions (32%), and investing in improving information systems to assist managers in decision-making (30 %). Implementing the situation concerning investing in improving information systems to assist managers in decision-making (37%) brought about by the nurse managers, the options and percentages for the other situations are very close.

Regarding the State Health Secretariat, the following stood out: expanding financial support for strategic programs aimed at improving access to the population (66%), investing in improving access to appointments, hospitalizations, tests and medicines in quantity and quality (58%) and implementing a comprehensive training process for municipal managers (38%), statements that are common among nurse managers and other managers.

When analyzing the composition of actions by manager, we observed that the other managers were emphatic regarding expanding financial support for strategic programs aimed at improving access to the population (67%), investing in improving access to appointments, hospitalizations, exams and medicines in quantity and quality (59%), while nurse managers, in implementing a comprehensive training process for municipal managers (38%).

Regarding the Council of Municipal Health Secretaries (COSEMS), the following were highlighted: Assisting managers in dialogue with control bodies and the judiciary (49%) strengthening the regional actions of the Council of Health Secretaries - COSEMS (42%) and holding workshops and courses on priority topics seizing the opportunity of the week of CIR meetings (36%).

When we look at the composition of the actions, we found that, despite an alignment between the managers, worth highlighting were: assisting managers in dialogue with control bodies and the judiciary (50%) and holding workshops and courses on priority topics seizing the opportunity of the week of CIR meetings (39%), for other managers, and concerning nurse managers, strengthening the regional actions of the Council of Health Secretariats – COSEMS (43%).

Final considerations

The aspects addressed in the text were analyzed with reference to theoretical elements that point to the reflection on a strategic actor, who has an essential participation in the construction of management practices in SUS, and has occupied several spaces in the coordination of primary care actions, strategic areas spearheading programs and services, coordination of teams, sectors and notably the participation as municipal manager in the SUS.

The strength of the female presence in the conduction of municipal management agendas, with higher education and postgraduate studies, deriving from primary care and strongly linked in the area of nursing, was evident.

Even without previous management experience, but with firm positions regarding the possibilities of acting in the conduction of local health actions and services, the nurse managers claim to have the mayor's trust, technical competence. They can lead, mobilize, and dialogue, requirements that we can point out as primordial for local management practices and processes.

With regard to management challenges, the concern of nurse managers was explicit, with themes inherent in ensuring stable and sustainable financing for the SUS, with emphasis on primary care; the improved access to appointments and examinations and the strengthening of the CIR as a qualification space for regionalization, training of management teams, ensuring the provision of workers, qualification of health counselors and the expanded dialogue with the control bodies.

Among the political actors, the strength of the mayors, the health council and the Ministry of Health in the decision-making of the nurse managers was explicit, and the state's situation in this context is of concern, a fact that promotes an in-depth study, given the level of the challenges shown.

The agendas from the health councils, the CIR, and the audit reports stood out as guiding line of the conduct of nurse managers, revealing a concern with listening to local society, the qualification of the regional agenda, and situations that broaden their relationship with control and evaluation of the SUS.

Regarding the main agendas to be developed by managers, they correlate with the challenges identified, and the main highlight is the increased resources for strategic programs aimed at improving people's access to appointments and examinations, qualification of managers, strengthening of the regional management spaces and qualification of the dialogue with the control bodies.

Thus, the results show the need for new readings, allowing a qualified view on the findings, as studies of this nature highlight a set of challenges that point the municipal manager as a strategic actor, and in particular, nursing professionals who, in assuming this mission, must have their path, desires and perceptions thoroughly studied.

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