Abstract

Co-management is one of the guiding principles of Brazil’s National Humanization Policy (NHP), which has been studied since its creation in 2003. This article presents an integrative review of literature on co-management in the context of the NHP. We performed searches of the VHL, CAPES, Scopus and ProQuest databases for articles on co-management published after the creation of the NHP. We conducted a detailed analysis of 36 articles, organizing the results into two predefined categories: theoretical bases and reports on co-management in practice. The articles drew on the following theoretical bases: the circle method/institutional support, ergology, Hermeneutics, schizoanalysis, Habermas’ theory of communicative action and Paulo Freire’s pedagogy for liberation. Few studies provided original theoretical contributions. Regarding practice, the authors mentioned the implementation of co-management devices and the creation of different collective spaces, which were presented as a being participatory in themselves. The articles offered little reflection on the process of developing a culture of participation. We conclude by pointing to the need for studies that explore the relational construction of co-management in the everyday practice of health care teams.

Key words:
Health management; Humanization of care; Co-management

Introduction

The management approach suggested by Brazil’s National Humanization Policy (NHP) - co-management or participatory management - is largely based on the work of Campos¹1 Campos GWS. Um método para análise e co-gestão de Coletivos. 3a ed. São Paulo: Hucitec; 2007., the most cited author in the NHP reference guide Participatory management and co-management published by the Ministry of Health²2 Brasil. Política Nacional de Humanização da Atenção e Gestão do SUS. Gestão Participativa e Cogestão. Série B. Textos Básicos de Saúde, Brasília: Ministério da Saúde; 2012..

According to Pereira et al.³3 Pereira AB, Ferreira Neto JL. Processo de implantação da Política Nacional de Humanização em Hospital Geral Público. Trab Educ Saude 2015; 13(1):67-88., in 2003, the year when the NHP was created, Campos took up the post of executive secretary of the Executive Secretariat of the Ministry of Health, when a series of his concepts were incorporated into the ministry’s policies. For this reason, and due to the findings of this review, we believe it is important to outline some of the basic guiding principles of his work and method, which have been widely disseminated in relation to co-management.

However, it is important to highlight that participatory management is a broad term that has been discussed in Brazil since the time of the health reform movement⁴4 Coelho JS. Construindo a participação social no SUS: um constante repensar em busca de equidade e transformação. Saúde e Sociedade 2012; 21(Supl. 1):138-151., which emerged during the redemocratization process, and subsequent creation of spaces for public participation, such as community health councils⁵5 Carvalho AI. Conselhos de Saúde no Brasil: Participação Cidadã e Controle Social. Rio de Janeiro: IBAM/FASE; 1995.^,66 Serapioni M, Romani O. Potencialidades e desafios da participação em instâncias colegiadas dos sistemas de saúde: os casos de Itália, Inglaterra e Brasil. Cad Saude Publica 2006; 22(11):2411-2421.. This topic has also been studied since the creation of the Ministry of Health’s Participatory Management Secretariat and formulation of the National Participatory Management Policy⁴4 Coelho JS. Construindo a participação social no SUS: um constante repensar em busca de equidade e transformação. Saúde e Sociedade 2012; 21(Supl. 1):138-151.^,77 Lopes MCR, Matta GC. SUS, gestão participativa e equidade. In: Guizardi FL, Nespoli G, Cunha LMS, Machado F, Lopes M organizadores. Políticas de Participação e Saúde. 1ª ed. Recife: Editora Universitária UFPE; 2014. p. 305-324.^,88 Marinho PS. Gestão Participativa nas políticas públicas no âmbito do Sistema Único de Saúde: principais componentes e desafios. Cadernos Ibero-Americanos de Direito Sanitário 2015; 4(1):120-142.. Not to mention research on co-management by other branches of knowledge within sociology⁹9 Sandström C. Institutional Dimensions of Comanagement: Participation, Power and Process. Society & Natural Resources 2009; 22:230-240. and the study of participatory management models in the fields of business administration and organizational psychology¹⁰10 Koopman PL, Wierdsma AFM. Participative Management. In. Drenth PJD, Thierry H, Wolff CJ editors. Handbook of Work and Organizational Psychology. East Sussex, UK: Psychology Press Ltda; 1998. p. 297-317..

Participatory models gained momentum in the 1960s and 70s and can be divided into three categories: models in which participation is considered a right; models related to humanization in which participation leads to greater commitment and better work performance; and participation as a way of controlling operations, a coordination mechanism, as suggested by Mintzberg¹⁰10 Koopman PL, Wierdsma AFM. Participative Management. In. Drenth PJD, Thierry H, Wolff CJ editors. Handbook of Work and Organizational Psychology. East Sussex, UK: Psychology Press Ltda; 1998. p. 297-317..

The description of the history of current management models and their incorporation within the field of health¹¹11 West E. Management matters: the link between hospital organisation and quality of patient care. Quality in Health Care 2001; 10:40-48.^,1212 Blaise P, Kegels G. A realistic approach to the evaluation of the quality management movement in health care systems: a comparison between European and African contexts based on Mintzberg's organizational models. Int J Health Plan and Management 2004; 19: 337-364. is beyond the scope of this article, which seeks to analyze literature on co-management produced after its inclusion as one of the guiding principles of the NHP²2 Brasil. Política Nacional de Humanização da Atenção e Gestão do SUS. Gestão Participativa e Cogestão. Série B. Textos Básicos de Saúde, Brasília: Ministério da Saúde; 2012.. Below we therefore outline the core tenets of Campos’ work¹1 Campos GWS. Um método para análise e co-gestão de Coletivos. 3a ed. São Paulo: Hucitec; 2007..

Drawing on concepts of business administration and other areas of knowledge such as politics, psychology, philosophy and pedagogy, Campos¹1 Campos GWS. Um método para análise e co-gestão de Coletivos. 3a ed. São Paulo: Hucitec; 2007. created the circle method (método da roda, meaning literally the wheel method) to analyze and co-manage groups. The method is shaped around four core elements: 1) anti-Taylorism; 2) strengthening subjects and institutional democracy; 3) conceptual reconstruction and work practice; 4) a dialectical worldview¹1 Campos GWS. Um método para análise e co-gestão de Coletivos. 3a ed. São Paulo: Hucitec; 2007..

In the first element, Campos¹1 Campos GWS. Um método para análise e co-gestão de Coletivos. 3a ed. São Paulo: Hucitec; 2007. situates his creation as a possible alternative to other management theories, in particular Taylor’s classical management theory. In this regard, the author draws on an amalgamation of other theories to create a theoretical framework that underpins proposed practice. The method seeks to establish co-management systems in order to produce solidarity towards the public interest and “autonomous and protagonistic subjectivities”. The second element encompasses two of the method’s central aims: strengthening subjects and building institutional democracy, focusing on the creation of collective spaces. In the third element, drawing on the works of Marx, Campos¹1 Campos GWS. Um método para análise e co-gestão de Coletivos. 3a ed. São Paulo: Hucitec; 2007. reconstructs the concept of “labor”, which is considered an essential component of subjects, groups and society. Finally, the forth element alludes to the dialectical worldview underpinning the method.

According to Campos, the creation of collective spaces has three core functions: 1) a management and planning function; 2) political function, involving changing power relations and the construction of democracy; and 3) a pedagogical and therapeutic function, so-called insofar as it influences the production of subjectivities, a process that he calls the “paideia factor”. Campos¹1 Campos GWS. Um método para análise e co-gestão de Coletivos. 3a ed. São Paulo: Hucitec; 2007. concludes that the idea is to:

Although he recognizes the possibility of various types of collective spaces depending on the context, Campos¹1 Campos GWS. Um método para análise e co-gestão de Coletivos. 3a ed. São Paulo: Hucitec; 2007. describes four main forms: co-management councils; collegial management bodies; devices; and dialogue and decision-making in the day-to-day functioning of an organization. The author also presents the possibility of applying the “institutional support method” (taking its theoretical base from the institutionalist movement), internally or with the support of an external agent. The external “supporter” helps the group analyze its work processes and relations and should therefore have an understanding of group dynamics and the affects that circulate from transference and countertransference¹1 Campos GWS. Um método para análise e co-gestão de Coletivos. 3a ed. São Paulo: Hucitec; 2007..

Thus, although Campos¹1 Campos GWS. Um método para análise e co-gestão de Coletivos. 3a ed. São Paulo: Hucitec; 2007. does not put it this way and suggests institutional support as a practice, it is important to consider that to undertake this type of analysis the supporter should have a specific set of skills and knowledge about group dynamics and process theories and human relations. Furthermore, given that the role of the supporter is to identify group dynamics and the affects that circulate from transference and countertransference, this type of analysis also requires knowledge of the basic concepts of psychoanalysis and psychology. Thus, the supporter must be adequately qualified. Otherwise, there is a risk of leaving empty spaces in the analysis, as the simple opening of the circle is not enough to build change.

To make it more accessible, Campos’s work¹1 Campos GWS. Um método para análise e co-gestão de Coletivos. 3a ed. São Paulo: Hucitec; 2007. was described in a simplified manner in a NHP reference guide²2 Brasil. Política Nacional de Humanização da Atenção e Gestão do SUS. Gestão Participativa e Cogestão. Série B. Textos Básicos de Saúde, Brasília: Ministério da Saúde; 2012.. Produced by the Ministry of Health, the guide states that the management model adopted by the NHP is centered on team working: Management is not a place, space or field of action exclusive to experts. Everyone does management²2 Brasil. Política Nacional de Humanização da Atenção e Gestão do SUS. Gestão Participativa e Cogestão. Série B. Textos Básicos de Saúde, Brasília: Ministério da Saúde; 2012. (p. 23). The prefix “co” in “co-management” suggests two inclusions: 1) the participation of subjects in management processes; 2) the broadening of the functions of management. Rather than just keeping the organization running, management should aim to analyze the organization in order to problematize models of operating/acting and promote change, formulate projects, share decision-making, and foster pedagogical spaces for mutual teaching and learning²2 Brasil. Política Nacional de Humanização da Atenção e Gestão do SUS. Gestão Participativa e Cogestão. Série B. Textos Básicos de Saúde, Brasília: Ministério da Saúde; 2012.. Therefore, it is envisaged that participation should be incorporated into the everyday routine of services, not just into specific spaces such as community health councils and health councils.

Considering that the NHP is an open policy that seeks to foster the participation of subjects in actions tailored to specific contexts, without specific rules and regulations, professionals encounter a wide variety of experiences in everyday practice, many of which have not been published as empirical studies. However, many experiences have been posted on the Rede HumanizaSUS¹³13 Fontoura AMT. Arranjos e estratégias de cogestão em maternidades públicas [dissertação]. Rio de Janeiro: Fundação Oswaldo Cruz; 2017. (literally the “Humanize the SUS Network”, where SUS is the acronym for Sistema Único de Saúde, Brazil’s national health service), a social media network designed to encourage local services across the country to build their own individual ways of understanding and sharing management. In view of the above, the aim of this study was to undertake a review of literature on co-management, with the understanding that this analysis does not encompass all the experiences in this area in Brazil.

The general objective was to carry out a review of existing literature on co-management in Brazil published after the creation of the NHP in 2003. The specific objectives were: a) to identify the theoretical bases used to discuss the topic; and b) to identify reports on how co-management has been practiced.

According to Botelho, Cunha and Macedo¹⁴14 Botelho LLR, Cunha CCA, Macedo M. O método da revisão integrativa nos estudos organizacionais. Gestão Soc 2011; 5(11):121-136., the literature review process is the first step in the knowledge construction process, as it creates openings for new research by identifying gaps in existing literature. In this regard, the current review offers researchers in this field a general overview of a significant body of literature, while at the same time encouraging the publication of experiences not encompassed by the articles analyzed.

Method

We used the integrative review method. This type of review aims to analyze the body of knowledge on the topic of concern, providing a synthesis of the data and indicating new directions for future research¹⁴14 Botelho LLR, Cunha CCA, Macedo M. O método da revisão integrativa nos estudos organizacionais. Gestão Soc 2011; 5(11):121-136.^,1515 Mendes KDS, Silveira RCCP, Galvão CM. Revisão Integrativa: método de pesquisa para a incorporação de evidências na saúde e na Enfermagem. Texto & Contexto Enfermagem 2008; 17(4):758-764..

According to Mendes et al.¹⁵15 Mendes KDS, Silveira RCCP, Galvão CM. Revisão Integrativa: método de pesquisa para a incorporação de evidências na saúde e na Enfermagem. Texto & Contexto Enfermagem 2008; 17(4):758-764., the integrative review process includes the completion and description of all stages. Although the literature on this type of review points to the need to synthesize and describe these stages, the subdivision of these stages varies from author to author.

The current review followed the stages defined by Mendes et al.¹⁵15 Mendes KDS, Silveira RCCP, Galvão CM. Revisão Integrativa: método de pesquisa para a incorporação de evidências na saúde e na Enfermagem. Texto & Contexto Enfermagem 2008; 17(4):758-764.: formulation of the guiding question; definition of article selection and exclusion criteria; testing to define descriptors/keywords; choice of platforms and descriptors; abstract and title screening; preliminary selection; detailed reading and charting; selection refinement; and analysis, interpretation and presentation of results.

Guiding question

Considering that the NHP suggests that the implementation of guidelines should be tailored to the local context, we formulated the following question: How has management, or more specifically, the principle of co-management, been discussed and reported in practice since the creation of the policy in 2003? This question includes two categories for subsequent analysis: a) theoretical bases; and b) reports of co-management in practice.

Preliminary selection criteria

The selection criteria for title and abstract screening were articles whose central theme was co-management models in public health settings in Brazil or health management and work processes grounded in the NHP reference guide²2 Brasil. Política Nacional de Humanização da Atenção e Gestão do SUS. Gestão Participativa e Cogestão. Série B. Textos Básicos de Saúde, Brasília: Ministério da Saúde; 2012..

Exclusion criteria

After preliminary selection and detailed reading of the publications, articles where the theme was not the object of study or central to the discussion were excluded.

Testing, choice of platforms and preliminary selection

The tests and searches were performed in 2016. An initial search was conducted of the Virtual Health Library (VHL), which was chosen because it is the most widely used health database in Brazil. After performing a number of tests using different descriptors and/or keywords, the search that yielded most records was that using the keywords “Management AND Humanization”, resulting in 429 texts. After applying a filter restricting the search to year of publication - between 2003 (the year when the NHP was created) and 2016 - 404 records remained, including articles, books and theses.

Forty-five of these records (11% of the total) met the preliminary selection criteria. Twenty-four duplicates of these 45 records were not counted. The other 335 records were categorized as follows: 49% addressed the policy but focused on other provisions/guiding principles; 4% were about professional training; 2% focused on psychology or odontology in a health context; 28% dealt with other issues related to humanization, such as organ donation, treatments, etc.

We performed a second search of the CAPES (Coordination of Improvement of Higher Education Personnel) Periodical Portal, which brings together multidisciplinary databases. After testing, we chose the keywords “health management AND humanization”, resulting in 53 records, 15 of which met the preliminary selection criteria. Of these, six had already been found in the search of the VHL and seven were duplicates, resulting in only two additional articles. The other records were categorized as follows: 17% addressed humanization but had a different focus; 13% focused on other issues related to humanization; 4% were about biotechnology; and 38% dealt with a range of different topics, such as ceramic coating of carbon composites for example.

We conducted a third search of the Scopus portal, which brings together multidisciplinary databases covering different areas. The keywords that yielded most results were “health management AND humanization”, resulting in 155 records, 21 of which met the preliminary selection criteria. Of these, 16 had already been found in the search of the VHL and one in the CAPES portal, resulting in only four additional records. The other records were categorized as follows: 60% addressed humanization but had a different focus; 14% were discussions in the field of health related to humanization; 2% focused on management in other contexts; and 10% dealt with a range of different topics.

We conducted a fourth search of the ProQuest portal, which brings together databases covering different areas. The combination of keywords and descriptors that yielded most results was “Health Management AND Humanization of Work OR Humanization”, resulting in 35 results, four of which met the preliminary selection criteria. Of these, one had already been found on the VHL, Scopus and CAPES portals and one in the VHL and Scopus portals, resulting in only two additional records. The other records were categorized as follows: 26% addressed humanization but had a different focus; 46% focused on work management outside the field of health; 3% were about humanization in other areas; and 14% dealt with general health issues.

The preliminary selection of the records found in the four searches resulted in a total of 53 records: 45 from the VHL, four from Scopus, two from ProQuest and two from the CAPES Periodical Portal.

After searching for the full-text versions of these publications and detailed reading and charting, 17 publications were excluded, resulting in a final sample of 36 articles. The excluded publications included articles whose full-text was not available, theses or dissertations referring to published articles, and articles in which the discussion was not centered on management in the context of the NHP. Chart 1 shows the articles by year of publication.

Analysis

In the reading and charting stage, we developed a charting table for each article in Microsoft Excel (containing title, authors, author’s academic background, year of publication, journal, abstract, method, conclusions) and analyzed the articles focusing on the two categories mentioned above (theoretical bases and reports on practice).

After charting, we read the articles and reduced the information into a single Excel worksheet containing the following information: 1) article title; 2) author’s academic background; 3) year of publication; 4) journal; 5) theoretical bases; 6) reports on practice; and 7) database. Based on this information, we conducted an analysis of the articles using the Excel filter function, which counts items of information in the worksheet.

The discussion of this analysis, especially with regard to theoretical bases and reports on practice, draws on Campos¹1 Campos GWS. Um método para análise e co-gestão de Coletivos. 3a ed. São Paulo: Hucitec; 2007. and the NHP reference guide mentioned above²2 Brasil. Política Nacional de Humanização da Atenção e Gestão do SUS. Gestão Participativa e Cogestão. Série B. Textos Básicos de Saúde, Brasília: Ministério da Saúde; 2012..

To perform the analysis of the categories, it was necessary to extract elements from the articles (often highlighting secondary aspects of the text), meaning that the review presented here is a construction of meaning¹⁶16 Spink MJP, organizador. Práticas discursivas e produção de sentidos no cotidiano: aproximações teóricas e metodológica. 3ª ed. São Paulo: Cortez; 2004. with the specific aim of exploring the field. This construction therefore brings to light aspects that were not necessarily intentionally revealed by the authors.

Results

With regard to year of publication, 5.5% of the articles were published between 2006 and 2008, 25% in 2009, 11% in 2011, 14% in 2012, 6% in 2013, 30% in 2014, and 8.3% between 2015 and 2016. The findings show that there were spikes in the number of articles published in 2009 and 2014. This may be explained by the fact that these years were the fifth and 10^th anniversaries of the NHP, respectively, since journals tend to publish special thematic issues on commemorative dates.

This hypothesis is supported by an analysis of the journals in which the articles were published, with the journal Interface accounting for the majority of publications (18 articles), followed by the Journal of Science and Public Health (4 articles). In 2014, Interface published a special issue entitled “Institutional Support for the Humanization Policy”. Of the 18 articles published by this journal, 10 were from the special issue. The remaining publications consisted of two articles each in the journals Health and Society and Work, Education and Health, one in other journals (Reports in Public Health, The World of Health, Physis: Journal of Public Health, Pan-Amazonian Journal of Health, Public Health Journal, Health in Debate, Texts and Contexts) and two Ministry of Health guides.

With regard to academic background, most of the authors (38%) had a degree in psychology, followed by nursing (23%), medicine (17%), dentistry and social work (each with 4.7%), social sciences (1.57%), physical education (3%), occupational therapy (3%), and information not available (3.10%). These findings may be explained by the fact that, as the reference guide states, NHP intersects with psychology, converging towards subjective issues such as interpersonal relations and, in the case of management, organizational, educational and institutional psychology.

Theoretical bases

The analysis of the theoretical bases used in the articles proved to be a complex task. Some articles adopt a specific epistemological frame of reference, engaging with authors who share the same perspective or with other authors who use different frames of reference, always highlighting the central epistemological differences. However, others draw on different epistemological perspectives and a range of authors, in some cases making it difficult to identify a specific theoretical base or determine whether various authors are cited by choice or due to lack of knowledge about the field.

In general, the discussions in the introductions and/or analyses were built on the following theoretical bases: theoretical frameworks developed around other classical theories that gave rise to the circle/institutional support methods¹1 Campos GWS. Um método para análise e co-gestão de Coletivos. 3a ed. São Paulo: Hucitec; 2007.; schizoanalysis (Deleuze and Guattari); ergology (Schwartz); Hermeneutics (authors such as Gadamer and Heidegger); notions from the field of sociology (Habermas) and pedagogy (Paulo Freire). All of these perspectives, except ergology, were used by Campos¹1 Campos GWS. Um método para análise e co-gestão de Coletivos. 3a ed. São Paulo: Hucitec; 2007. to develop the circle method.

One of the central findings of this review is therefore the evident dissemination of Campos’ work as a reference for co-management in the NHP, possibly due to the publication of the reference guide. This does not necessarily mean that Campos’s work is the origin of participatory management models, as suggested in the introduction. However, the author’s influence on the studies could lead one to believe that this body of knowledge was produced solely by Campos. This aspect is therefore an important gap to be addressed by future studies aimed at revisiting the origins of participatory management and the emergence of co-management within the field of health.

Some of the articles specifically address the institutional support method proposed by Campos¹⁷17 Mori ME, Oliveira OVM. Os coletivos da Política Nacional de Humanização (PNH): a cogestão em ato. Interface (Botucatu) 2009; 13(Supl. 1):627-40.

18 Pereira AB, Ferreira Neto JL. Processo de implantação da Política Nacional de Humanização em Hospital Geral Público. Trab Educ Saude 2015; 13(Supl. 1):67-88.

19 Mori ME, Oliveira OVM. Apoio institucional e cogestão: a experiência da Política Nacional de Humanização no Sistema Único de Saúde (SUS) no Distrito Federal, Brasil. Interface (Botucatu) 2014; 18:1063-1075.

20 Shimizu HE, Martins T. O apoio institucional como método de análise-intervenção na Atenção Básica no Distrito Federal, Brasil. Interface (Botucatu) 2014; 18:1077-1087.

21 Martins CP, Luzio CA. Experimentações no apoio a partir das apostas da Política Nacional de Humanização - HumanizaSUS. Interface (Botucatu) 2014; 18:1099-1106.

22 Maerschner RL, Bastos ENE, Gomes AMA, Jorge MSB, Diniz SAN. Apoio institucional - reordenamento dos processos de trabalho: sementes lançadas para uma gestão indutora de reflexões. Interface (Botucatu) 2014; 18:1089-1098.

23 Pinheiro MEC, Jesus LMM. Apoio institucional como diretriz de gestão da 7a Diretoria Regional de Saúde, Bahia, Brasil. Interface (Botucatu) 2014; 18:1135-1143.

24 Calderon DBL, Verdi MIM. Cogestão e processo de intervenção de apoiadores da Política Nacional de Humanização (PNH). Interface (Botucatu) 2014; 18(Supl. 1):859-870.

25 Santos Filho SB. Apoio institucional e análise do trabalho em saúde: dimensões avaliativas e experiências no Sistema Único de Saúde (SUS). Interface (Botucatu) 2014; 18: 1013-1025.

26 Pavan, C, Trajano ARC. Apoio institucional e a experiência da Política Nacional de Humanização (PNH) na Freguesia do Ó, Brasilândia, São Paulo, Brasil. Interface (Botucatu) 2014; 18(Supl.1):1027-1040.

27 Roza MMR, Barros MEB, Guedes CR, Santos Filho SB. A experiência de um processo de formação articulando humanização e apoio institucional no trabalho em saúde. Interface (Botucatu) 2014; 18(Supl. 1):1041-1052.

28 Andrade MAC, Barros SMM, Maciel NP, Sodré F, Lima RCD. Apoio institucional: estratégia democrática na prática cotidiana do Sistema Único de Saúde (SUS). Interface (Botucatu) 2014; 18 (Supl. 1): 833-844.

29 Guedes CR, Roza MMR, Barros MEB. O apoio institucional na Política Nacional de Humanização: uma experiência de transformação das práticas de produção de saúde na rede de atenção básica. Cad Saude Colet 2012; 20(1):93-101.

30 Santos Filho SB, Barros MEB, Gomes RS. A Política Nacional de Humanização como política que se faz no processo de trabalho em saúde. Interface (Botucatu) 2009; 13:603-613.

31 Guedes CR, Pitombo LB, Barros MEB. Os processos de formação na Política Nacional de Humanização: a experiência de um curso para gestores e trabalhadores da atenção em saúde. Physis 2009; 19(4):1087-1109.

32 Barros MEB, Guedes CR, Roza MMR. O apoio institucional como método de análise-intervenção no âmbito das políticas públicas de saúde: a experiência em um hospital geral. Cien Saude Colet 2011; 16(12):4803-1814.^-3333 Cardoso JR, Oliveira GN, Furlan PG. Gestão democrática e práticas de apoio institucional na Atenção Primária à Saúde no Distrito Federal, Brasil. Cad Saude Publica 2016; 32(3): e00009315.. Santos Filho²⁵25 Santos Filho SB. Apoio institucional e análise do trabalho em saúde: dimensões avaliativas e experiências no Sistema Único de Saúde (SUS). Interface (Botucatu) 2014; 18: 1013-1025. analyzes institutional support drawing on notions of ergology proposed by Schwartz and Zarifian, which include pertinent discussions about the importance of addressing relations and communication for promoting change.

Other articles use the guiding principles of the NHP and/or the discussion presented in Campos’ book¹1 Campos GWS. Um método para análise e co-gestão de Coletivos. 3a ed. São Paulo: Hucitec; 2007. as their theoretical basis, with some focusing specifically on management and others examining other aspects of policy³⁴34 Pasche DF. Política Nacional de Humanização como aposta na produção coletiva de mudanças nos modos de gerir e cuidar. Interface (Botucatu) 2009; 13(Supl. 1):701-708.

35 Rios IC, Battistella LR. Gestão da humanização das práticas de saúde: o caso do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo. Saaude Soc 2013; 22(3):853-865.

36 Granja GF, Zoboli ELCP. Humanização da Atenção Primária à Saúde: Gestão em redes e governança local. O Mundo da Saúde 2012; 36(3):494-501.

37 Santos Filho SB, Figueiredo VON. Contratos internos de gestão no contexto da Política de Humanização: experimentando uma metodologia no referencial da cogestão. Interface (Botucatu) 2009; 13:615-626.

38 Deus AD, Melo EM. Avaliação de uma experiência de gestão hospitalar participativa no âmbito do SUS: produção de saúde, sujeitos de coletivos. Saude Debate 2015; 39(106):601-615.

39 Mori ME, Silva FH, Beck FL. Comunidade Ampliada de Pesquisa (CAP) como dispositivo de cogestão: uma aposta no plano coletivo. Interface (Botucatu) 2009; 13 (Supl. 1):719-727.^-4040 Trad LAB, Espiridião MA. Gestão Participativa e corresponsabilidade em saúde: limites e possibilidades no âmbito da ESF. Interface (Botucatu) 2009; 13 (Supl. 1):557-570.. From a theoretical point of view, these articles do not seem to add new ideas to the theories and concepts put forward by Campos¹1 Campos GWS. Um método para análise e co-gestão de Coletivos. 3a ed. São Paulo: Hucitec; 2007.. However, the conceptual relations may be considered innovative depending on the perspective of the analysis. Generally speaking, articles describe experiences or field studies using a traditional frame of reference³⁵35 Rios IC, Battistella LR. Gestão da humanização das práticas de saúde: o caso do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo. Saaude Soc 2013; 22(3):853-865.

36 Granja GF, Zoboli ELCP. Humanização da Atenção Primária à Saúde: Gestão em redes e governança local. O Mundo da Saúde 2012; 36(3):494-501.

37 Santos Filho SB, Figueiredo VON. Contratos internos de gestão no contexto da Política de Humanização: experimentando uma metodologia no referencial da cogestão. Interface (Botucatu) 2009; 13:615-626.^-3838 Deus AD, Melo EM. Avaliação de uma experiência de gestão hospitalar participativa no âmbito do SUS: produção de saúde, sujeitos de coletivos. Saude Debate 2015; 39(106):601-615.^,4040 Trad LAB, Espiridião MA. Gestão Participativa e corresponsabilidade em saúde: limites e possibilidades no âmbito da ESF. Interface (Botucatu) 2009; 13 (Supl. 1):557-570., with only one presenting methodological innovations³⁹39 Mori ME, Silva FH, Beck FL. Comunidade Ampliada de Pesquisa (CAP) como dispositivo de cogestão: uma aposta no plano coletivo. Interface (Botucatu) 2009; 13 (Supl. 1):719-727..

Other theoretical bases identified in the articles include schizoanalysis, first expounded by Deleuze and Guattari⁴¹41 Pasche DF, Passos E, Hennington EA. Cinco anos da Política Nacional de Humanização: trajetória de uma política pública. Cien Saude Colet 2011; 16(11):4541-4548.^,4242 Ceccim RB, Merhy EE. Um agir micropolítico e pedagógico intenso: a humanização entre laços e perspectivas. Interface (Botucatu) 2009; 13(Supl. 1):531-542.. Some articles did not explicitly mention schizoanalysis, but used terms and notions that are specific to the field and were therefore grouped in this category. Schizoanalysis is a line stemming from the institutionalist movement. It is grounded in psychoanalysis and, like other lines of thought stemming from the movement, it aims to promote the analysis of the day-to-day functioning of organizations. As Baremblitt⁴³43 Baremblitt G. Compêndio de Análise Institucional e outras correntes. Teoria e Prática 2ª ed. Rio de Janeiro: Editora Rosa dos tempos; 1994. states, The different schools of the institutionalist movement propose to foster, support and trigger processes of self-analysis and self-management in communities, collectives and groups of people (p. 14).

Ergology also appears as an important frame of reference for discussing work processes and co-management⁴⁴44 Heckert ALC, Passos E, Barros MEB. Um seminário dispositivo: a humanização do Sistema de Saúde (SUS) em debate. Interface (Botucatu) 2009; 13(Supl. 1):493-502.^,4545 Hennington EA. Gestão dos processos de trabalho e humanização em saúde: reflexões a partir da ergologia. Rev Saude Publica 2008; 42(3):555-561.^,2020 Shimizu HE, Martins T. O apoio institucional como método de análise-intervenção na Atenção Básica no Distrito Federal, Brasil. Interface (Botucatu) 2014; 18:1077-1087.. Ergology, as defined by its founder Yves Schwartz, is the study of human activity and concrete everyday work. Its underlying notion is that work is always re-singularized or renormalized by the individual who performs it. There is no set standard; no matter how many rules are created, each worker has his/her own particular way of working⁴⁶46 Viegas MF. Histórico e conceitos da ergologia: entrevista com Yves Schwartz. Reflexão & Ação 2012; 21(1):327-340..

Finally, albeit less common, some articles drew on the following theoretical bases: 1) Hermeneutics, mainly considering the focus on intersubjective relationships⁴⁷47 Santos JGW, Santo MAAE. Administração de Recursos Humanos em Saúde e Humanização: o viés hermenêutico. Revista Pan-Amazônica de Saúde 2011; 2(3):51-58.; 2) Paulo Freire’s pedagogy for liberation ⁴⁸48 Ferreira JA, Araújo GC. Humanização na saúde: uma análise dos sentidos na óptica do trabalho cotidiano. Textos & Contextos 2014; 13(1):199-213., which discusses the construction of protagonism from the revelation of the dominant classes; and 3) notions of democracy proposed by the sociologist Jürgen Habermas in his work The Theory of Communicative Action⁴⁹49 Araújo CEL, Pontes RJS. Constituição de sujeitos na gestão em saúde: avanços e desafios da experiência de Fortaleza (CE). Cien Saude Colet 2012; 17(9):2357-2365..

Reports on co-management in practice

With regard to practical co-management arrangements, most of the articles referred to a combination of actions. Although we recognize the importance of analyzing possible combinations of actions and their outcomes, for the purposes of this article we opted to explore separate practices.

The articles describe experiences of co-management involving the institutional support method. This methodology is described by Campos¹1 Campos GWS. Um método para análise e co-gestão de Coletivos. 3a ed. São Paulo: Hucitec; 2007. and was adopted by Ministry of Health, which has been offering training courses for institutional supporters for some years.

The articles describe the implementation of institutional support through the following strategies: different types of meetings between professionals - case discussions, planning and evaluation, meetings with other services, conversation circles etc¹⁹19 Mori ME, Oliveira OVM. Apoio institucional e cogestão: a experiência da Política Nacional de Humanização no Sistema Único de Saúde (SUS) no Distrito Federal, Brasil. Interface (Botucatu) 2014; 18:1063-1075.

20 Shimizu HE, Martins T. O apoio institucional como método de análise-intervenção na Atenção Básica no Distrito Federal, Brasil. Interface (Botucatu) 2014; 18:1077-1087.

21 Martins CP, Luzio CA. Experimentações no apoio a partir das apostas da Política Nacional de Humanização - HumanizaSUS. Interface (Botucatu) 2014; 18:1099-1106.

22 Maerschner RL, Bastos ENE, Gomes AMA, Jorge MSB, Diniz SAN. Apoio institucional - reordenamento dos processos de trabalho: sementes lançadas para uma gestão indutora de reflexões. Interface (Botucatu) 2014; 18:1089-1098.^-2323 Pinheiro MEC, Jesus LMM. Apoio institucional como diretriz de gestão da 7a Diretoria Regional de Saúde, Bahia, Brasil. Interface (Botucatu) 2014; 18:1135-1143.^,2626 Pavan, C, Trajano ARC. Apoio institucional e a experiência da Política Nacional de Humanização (PNH) na Freguesia do Ó, Brasilândia, São Paulo, Brasil. Interface (Botucatu) 2014; 18(Supl.1):1027-1040.^,2222 Maerschner RL, Bastos ENE, Gomes AMA, Jorge MSB, Diniz SAN. Apoio institucional - reordenamento dos processos de trabalho: sementes lançadas para uma gestão indutora de reflexões. Interface (Botucatu) 2014; 18:1089-1098.^,3333 Cardoso JR, Oliveira GN, Furlan PG. Gestão democrática e práticas de apoio institucional na Atenção Primária à Saúde no Distrito Federal, Brasil. Cad Saude Publica 2016; 32(3): e00009315.^,3838 Deus AD, Melo EM. Avaliação de uma experiência de gestão hospitalar participativa no âmbito do SUS: produção de saúde, sujeitos de coletivos. Saude Debate 2015; 39(106):601-615.; meetings including service users³¹31 Guedes CR, Pitombo LB, Barros MEB. Os processos de formação na Política Nacional de Humanização: a experiência de um curso para gestores e trabalhadores da atenção em saúde. Physis 2009; 19(4):1087-1109.^,2626 Pavan, C, Trajano ARC. Apoio institucional e a experiência da Política Nacional de Humanização (PNH) na Freguesia do Ó, Brasilândia, São Paulo, Brasil. Interface (Botucatu) 2014; 18(Supl.1):1027-1040.; modification of health facility flow charts²⁴24 Calderon DBL, Verdi MIM. Cogestão e processo de intervenção de apoiadores da Política Nacional de Humanização (PNH). Interface (Botucatu) 2014; 18(Supl. 1):859-870.; creation of working groups²⁴24 Calderon DBL, Verdi MIM. Cogestão e processo de intervenção de apoiadores da Política Nacional de Humanização (PNH). Interface (Botucatu) 2014; 18(Supl. 1):859-870.^,2626 Pavan, C, Trajano ARC. Apoio institucional e a experiência da Política Nacional de Humanização (PNH) na Freguesia do Ó, Brasilândia, São Paulo, Brasil. Interface (Botucatu) 2014; 18(Supl.1):1027-1040.; creation of steering committees, collegial management bodies and management contracts¹⁷17 Mori ME, Oliveira OVM. Os coletivos da Política Nacional de Humanização (PNH): a cogestão em ato. Interface (Botucatu) 2009; 13(Supl. 1):627-40.^,1818 Pereira AB, Ferreira Neto JL. Processo de implantação da Política Nacional de Humanização em Hospital Geral Público. Trab Educ Saude 2015; 13(Supl. 1):67-88.^,2020 Shimizu HE, Martins T. O apoio institucional como método de análise-intervenção na Atenção Básica no Distrito Federal, Brasil. Interface (Botucatu) 2014; 18:1077-1087.

21 Martins CP, Luzio CA. Experimentações no apoio a partir das apostas da Política Nacional de Humanização - HumanizaSUS. Interface (Botucatu) 2014; 18:1099-1106.^-2222 Maerschner RL, Bastos ENE, Gomes AMA, Jorge MSB, Diniz SAN. Apoio institucional - reordenamento dos processos de trabalho: sementes lançadas para uma gestão indutora de reflexões. Interface (Botucatu) 2014; 18:1089-1098.^,2626 Pavan, C, Trajano ARC. Apoio institucional e a experiência da Política Nacional de Humanização (PNH) na Freguesia do Ó, Brasilândia, São Paulo, Brasil. Interface (Botucatu) 2014; 18(Supl.1):1027-1040.^,2929 Guedes CR, Roza MMR, Barros MEB. O apoio institucional na Política Nacional de Humanização: uma experiência de transformação das práticas de produção de saúde na rede de atenção básica. Cad Saude Colet 2012; 20(1):93-101.^,3333 Cardoso JR, Oliveira GN, Furlan PG. Gestão democrática e práticas de apoio institucional na Atenção Primária à Saúde no Distrito Federal, Brasil. Cad Saude Publica 2016; 32(3): e00009315.^,3838 Deus AD, Melo EM. Avaliação de uma experiência de gestão hospitalar participativa no âmbito do SUS: produção de saúde, sujeitos de coletivos. Saude Debate 2015; 39(106):601-615.; technical chambers and management collegiates²⁷27 Roza MMR, Barros MEB, Guedes CR, Santos Filho SB. A experiência de um processo de formação articulando humanização e apoio institucional no trabalho em saúde. Interface (Botucatu) 2014; 18(Supl. 1):1041-1052.; humanization forums²⁹29 Guedes CR, Roza MMR, Barros MEB. O apoio institucional na Política Nacional de Humanização: uma experiência de transformação das práticas de produção de saúde na rede de atenção básica. Cad Saude Colet 2012; 20(1):93-101.; policy and program management support groups³³33 Cardoso JR, Oliveira GN, Furlan PG. Gestão democrática e práticas de apoio institucional na Atenção Primária à Saúde no Distrito Federal, Brasil. Cad Saude Publica 2016; 32(3): e00009315.; technical visits¹⁸18 Pereira AB, Ferreira Neto JL. Processo de implantação da Política Nacional de Humanização em Hospital Geral Público. Trab Educ Saude 2015; 13(Supl. 1):67-88.; seminars, training courses and workshops¹⁹19 Mori ME, Oliveira OVM. Apoio institucional e cogestão: a experiência da Política Nacional de Humanização no Sistema Único de Saúde (SUS) no Distrito Federal, Brasil. Interface (Botucatu) 2014; 18:1063-1075.^,2020 Shimizu HE, Martins T. O apoio institucional como método de análise-intervenção na Atenção Básica no Distrito Federal, Brasil. Interface (Botucatu) 2014; 18:1077-1087.^,2323 Pinheiro MEC, Jesus LMM. Apoio institucional como diretriz de gestão da 7a Diretoria Regional de Saúde, Bahia, Brasil. Interface (Botucatu) 2014; 18:1135-1143.^,2626 Pavan, C, Trajano ARC. Apoio institucional e a experiência da Política Nacional de Humanização (PNH) na Freguesia do Ó, Brasilândia, São Paulo, Brasil. Interface (Botucatu) 2014; 18(Supl.1):1027-1040.^,2727 Roza MMR, Barros MEB, Guedes CR, Santos Filho SB. A experiência de um processo de formação articulando humanização e apoio institucional no trabalho em saúde. Interface (Botucatu) 2014; 18(Supl. 1):1041-1052.^,2929 Guedes CR, Roza MMR, Barros MEB. O apoio institucional na Política Nacional de Humanização: uma experiência de transformação das práticas de produção de saúde na rede de atenção básica. Cad Saude Colet 2012; 20(1):93-101..

Other articles not necessarily focusing on institutional support also described the composition of collective spaces for discussion, as recommended in the NHP guide, for example: humanization working groups and general meetings³⁵35 Rios IC, Battistella LR. Gestão da humanização das práticas de saúde: o caso do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo. Saaude Soc 2013; 22(3):853-865.^,5050 Becchi AC, Albiero ALM, Pavão FO, Pinto IS, Godoi AV, Dias BC, Gonçalves ECA, Cavalhero RF. Perspectivas atuais de cogestão em saúde: vivências do Grupo de Trabalho de Humanização na Atenção Primária à Saúde. Saude Soc 2013; 22(2):653-660.; spaces for permanent health education and conversation circles²⁸28 Andrade MAC, Barros SMM, Maciel NP, Sodré F, Lima RCD. Apoio institucional: estratégia democrática na prática cotidiana do Sistema Único de Saúde (SUS). Interface (Botucatu) 2014; 18 (Supl. 1): 833-844.^,3737 Santos Filho SB, Figueiredo VON. Contratos internos de gestão no contexto da Política de Humanização: experimentando uma metodologia no referencial da cogestão. Interface (Botucatu) 2009; 13:615-626.^,4949 Araújo CEL, Pontes RJS. Constituição de sujeitos na gestão em saúde: avanços e desafios da experiência de Fortaleza (CE). Cien Saude Colet 2012; 17(9):2357-2365.; team meetings⁵¹51 Cardoso CG, Hennington EA. Trabalho em Equipe e Reuniões Multiprofissionais de Saúde: uma construção à espera pelos sujeitos da mudança. Trab Educ Saude 2011; 9:85-112.; the creation of collegial management bodies and management contracts; co-management workshops and seminars³⁵35 Rios IC, Battistella LR. Gestão da humanização das práticas de saúde: o caso do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo. Saaude Soc 2013; 22(3):853-865.^,3737 Santos Filho SB, Figueiredo VON. Contratos internos de gestão no contexto da Política de Humanização: experimentando uma metodologia no referencial da cogestão. Interface (Botucatu) 2009; 13:615-626.; discussion seminars⁴⁴44 Heckert ALC, Passos E, Barros MEB. Um seminário dispositivo: a humanização do Sistema de Saúde (SUS) em debate. Interface (Botucatu) 2009; 13(Supl. 1):493-502.; administrative reforms and the creation of permanent negotiating tables (to discuss labor issues)³⁷37 Santos Filho SB, Figueiredo VON. Contratos internos de gestão no contexto da Política de Humanização: experimentando uma metodologia no referencial da cogestão. Interface (Botucatu) 2009; 13:615-626.; humanization technical units³⁵35 Rios IC, Battistella LR. Gestão da humanização das práticas de saúde: o caso do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo. Saaude Soc 2013; 22(3):853-865.; and promotion of staff participation in decision-making⁴⁸48 Ferreira JA, Araújo GC. Humanização na saúde: uma análise dos sentidos na óptica do trabalho cotidiano. Textos & Contextos 2014; 13(1):199-213..

Another strategy mentioned as co-management in practice was the so-called expanded research community³²32 Barros MEB, Guedes CR, Roza MMR. O apoio institucional como método de análise-intervenção no âmbito das políticas públicas de saúde: a experiência em um hospital geral. Cien Saude Colet 2011; 16(12):4803-1814.^,3939 Mori ME, Silva FH, Beck FL. Comunidade Ampliada de Pesquisa (CAP) como dispositivo de cogestão: uma aposta no plano coletivo. Interface (Botucatu) 2009; 13 (Supl. 1):719-727., which is a method used to analyze work processes. This strategy can be used to kickstart co-management (by promoting the analysis of work processes) or as a co-management practice itself.

The Ministry of Health guides identified by this review^2,52,53 discuss humanization in primary care settings, reinforcing patient participation⁵²52 Brasil. Ministério da Saúde (MS). HumanizaSUS na Atenção Básica. Brasília: MS; 2006. (Série B. Textos Básicos de Saúde) and presenting comprehensive technical guidelines for monitoring and evaluating proposals, seeking to promote humanization actions in a broad range of different contexts and dimensions (care and management) based on preset assessment parameters⁵³53 Brasil. Ministério da Saúde (MS). Monitoramento e Avaliação na Política Nacional de Humanização na Rede de Atenção e Gestão do SUS. Manual com eixos avaliativos e indicadores de referência. Brasília: MS; 2012. (Série B. Textos Básicos de Saúde). The guides also present specific guidance on co-management²2 Brasil. Política Nacional de Humanização da Atenção e Gestão do SUS. Gestão Participativa e Cogestão. Série B. Textos Básicos de Saúde, Brasília: Ministério da Saúde; 2012., listing the services where the organization of collective spaces should be put into practice.

Generally speaking, the creation of spaces to promote staff, management and, to a lesser extent, patient participation is common throughout the experiences. These spaces are described as opportunities for discussing, reflecting on and analyzing problems and needs in health facilities and identifying solutions.

Some of the articles highlight the need for greater adherence by managers to ensure the effective implementation of proposals²⁰20 Shimizu HE, Martins T. O apoio institucional como método de análise-intervenção na Atenção Básica no Distrito Federal, Brasil. Interface (Botucatu) 2014; 18:1077-1087.^,2222 Maerschner RL, Bastos ENE, Gomes AMA, Jorge MSB, Diniz SAN. Apoio institucional - reordenamento dos processos de trabalho: sementes lançadas para uma gestão indutora de reflexões. Interface (Botucatu) 2014; 18:1089-1098.^,2323 Pinheiro MEC, Jesus LMM. Apoio institucional como diretriz de gestão da 7a Diretoria Regional de Saúde, Bahia, Brasil. Interface (Botucatu) 2014; 18:1135-1143.^,2727 Roza MMR, Barros MEB, Guedes CR, Santos Filho SB. A experiência de um processo de formação articulando humanização e apoio institucional no trabalho em saúde. Interface (Botucatu) 2014; 18(Supl. 1):1041-1052.^,3232 Barros MEB, Guedes CR, Roza MMR. O apoio institucional como método de análise-intervenção no âmbito das políticas públicas de saúde: a experiência em um hospital geral. Cien Saude Colet 2011; 16(12):4803-1814.^,3939 Mori ME, Silva FH, Beck FL. Comunidade Ampliada de Pesquisa (CAP) como dispositivo de cogestão: uma aposta no plano coletivo. Interface (Botucatu) 2009; 13 (Supl. 1):719-727.. They also present various challenges, including: high staff turnover rates¹³13 Fontoura AMT. Arranjos e estratégias de cogestão em maternidades públicas [dissertação]. Rio de Janeiro: Fundação Oswaldo Cruz; 2017.^,2424 Calderon DBL, Verdi MIM. Cogestão e processo de intervenção de apoiadores da Política Nacional de Humanização (PNH). Interface (Botucatu) 2014; 18(Supl. 1):859-870., low level of participation in meetings¹³13 Fontoura AMT. Arranjos e estratégias de cogestão em maternidades públicas [dissertação]. Rio de Janeiro: Fundação Oswaldo Cruz; 2017.^,4040 Trad LAB, Espiridião MA. Gestão Participativa e corresponsabilidade em saúde: limites e possibilidades no âmbito da ESF. Interface (Botucatu) 2009; 13 (Supl. 1):557-570.; political changes and lack of physical space²⁷27 Roza MMR, Barros MEB, Guedes CR, Santos Filho SB. A experiência de um processo de formação articulando humanização e apoio institucional no trabalho em saúde. Interface (Botucatu) 2014; 18(Supl. 1):1041-1052.; lack of skills and experience in dealing with conflict²⁴24 Calderon DBL, Verdi MIM. Cogestão e processo de intervenção de apoiadores da Política Nacional de Humanização (PNH). Interface (Botucatu) 2014; 18(Supl. 1):859-870.; lack of time available for meetings¹⁹19 Mori ME, Oliveira OVM. Apoio institucional e cogestão: a experiência da Política Nacional de Humanização no Sistema Único de Saúde (SUS) no Distrito Federal, Brasil. Interface (Botucatu) 2014; 18:1063-1075.; low levels of patient participation²²22 Maerschner RL, Bastos ENE, Gomes AMA, Jorge MSB, Diniz SAN. Apoio institucional - reordenamento dos processos de trabalho: sementes lançadas para uma gestão indutora de reflexões. Interface (Botucatu) 2014; 18:1089-1098.; loss of job autonomy due to the need to discuss issues before making decisions²³23 Pinheiro MEC, Jesus LMM. Apoio institucional como diretriz de gestão da 7a Diretoria Regional de Saúde, Bahia, Brasil. Interface (Botucatu) 2014; 18:1135-1143..

In contrast, some of the articles highlight important changes in certain settings, including increased staff participation in decision-making and planning²²22 Maerschner RL, Bastos ENE, Gomes AMA, Jorge MSB, Diniz SAN. Apoio institucional - reordenamento dos processos de trabalho: sementes lançadas para uma gestão indutora de reflexões. Interface (Botucatu) 2014; 18:1089-1098.

23 Pinheiro MEC, Jesus LMM. Apoio institucional como diretriz de gestão da 7a Diretoria Regional de Saúde, Bahia, Brasil. Interface (Botucatu) 2014; 18:1135-1143.^-2424 Calderon DBL, Verdi MIM. Cogestão e processo de intervenção de apoiadores da Política Nacional de Humanização (PNH). Interface (Botucatu) 2014; 18(Supl. 1):859-870.^,2828 Andrade MAC, Barros SMM, Maciel NP, Sodré F, Lima RCD. Apoio institucional: estratégia democrática na prática cotidiana do Sistema Único de Saúde (SUS). Interface (Botucatu) 2014; 18 (Supl. 1): 833-844.^,2929 Guedes CR, Roza MMR, Barros MEB. O apoio institucional na Política Nacional de Humanização: uma experiência de transformação das práticas de produção de saúde na rede de atenção básica. Cad Saude Colet 2012; 20(1):93-101.^,5050 Becchi AC, Albiero ALM, Pavão FO, Pinto IS, Godoi AV, Dias BC, Gonçalves ECA, Cavalhero RF. Perspectivas atuais de cogestão em saúde: vivências do Grupo de Trabalho de Humanização na Atenção Primária à Saúde. Saude Soc 2013; 22(2):653-660.^,3232 Barros MEB, Guedes CR, Roza MMR. O apoio institucional como método de análise-intervenção no âmbito das políticas públicas de saúde: a experiência em um hospital geral. Cien Saude Colet 2011; 16(12):4803-1814., the creation of networking groups, and shifts in care and management models, with workers taking ownership of management practices²³23 Pinheiro MEC, Jesus LMM. Apoio institucional como diretriz de gestão da 7a Diretoria Regional de Saúde, Bahia, Brasil. Interface (Botucatu) 2014; 18:1135-1143..

Discussion

The findings show that the devices described in the NHP reference guide²2 Brasil. Política Nacional de Humanização da Atenção e Gestão do SUS. Gestão Participativa e Cogestão. Série B. Textos Básicos de Saúde, Brasília: Ministério da Saúde; 2012. are reported as instruments to guide practice. Although the most commonly cited devices are management collegiates and management contracts, all the other devices recommended in the NHP are mentioned, albeit to a lesser extent. This may be considered a positive finding, since it suggests that that the policy is being “applied in practice”. However, the simple “application” of the policy does not necessarily guarantee the success of a process like co-management, which was originally designed to take into account the subjective aspects of and communication between the participants in the process. Similarly, monitoring and evaluation strategies⁵³53 Brasil. Ministério da Saúde (MS). Monitoramento e Avaliação na Política Nacional de Humanização na Rede de Atenção e Gestão do SUS. Manual com eixos avaliativos e indicadores de referência. Brasília: MS; 2012. (Série B. Textos Básicos de Saúde) fail to encompass these aspects, appearing to be rigid and based on inconsistent techniques.

Although some articles make the important point that co-management does not consist simply of bringing together people in collective spaces, but rather should address subjectivities, relations and even conflicts¹²12 Blaise P, Kegels G. A realistic approach to the evaluation of the quality management movement in health care systems: a comparison between European and African contexts based on Mintzberg's organizational models. Int J Health Plan and Management 2004; 19: 337-364.^,2020 Shimizu HE, Martins T. O apoio institucional como método de análise-intervenção na Atenção Básica no Distrito Federal, Brasil. Interface (Botucatu) 2014; 18:1077-1087.

21 Martins CP, Luzio CA. Experimentações no apoio a partir das apostas da Política Nacional de Humanização - HumanizaSUS. Interface (Botucatu) 2014; 18:1099-1106.^-2222 Maerschner RL, Bastos ENE, Gomes AMA, Jorge MSB, Diniz SAN. Apoio institucional - reordenamento dos processos de trabalho: sementes lançadas para uma gestão indutora de reflexões. Interface (Botucatu) 2014; 18:1089-1098.^,2424 Calderon DBL, Verdi MIM. Cogestão e processo de intervenção de apoiadores da Política Nacional de Humanização (PNH). Interface (Botucatu) 2014; 18(Supl. 1):859-870.^,2626 Pavan, C, Trajano ARC. Apoio institucional e a experiência da Política Nacional de Humanização (PNH) na Freguesia do Ó, Brasilândia, São Paulo, Brasil. Interface (Botucatu) 2014; 18(Supl.1):1027-1040.^,4747 Santos JGW, Santo MAAE. Administração de Recursos Humanos em Saúde e Humanização: o viés hermenêutico. Revista Pan-Amazônica de Saúde 2011; 2(3):51-58.^,4949 Araújo CEL, Pontes RJS. Constituição de sujeitos na gestão em saúde: avanços e desafios da experiência de Fortaleza (CE). Cien Saude Colet 2012; 17(9):2357-2365.^,5151 Cardoso CG, Hennington EA. Trabalho em Equipe e Reuniões Multiprofissionais de Saúde: uma construção à espera pelos sujeitos da mudança. Trab Educ Saude 2011; 9:85-112., in general, the findings show that co-management - created to transform subjectivities and work processes - ends up being redefined.

The findings show that, in practice, co-management seems to have been transformed into promoting meetings that institutionalize spaces for dialogue, as if creating these spaces is a positive outcome in itself, suggesting, without the need for evaluation, that the group process is participatory. The way these experiences are described suggests that the method has been taken up as a new technique that, rather than promoting reflection, results in mere reproduction. As Mori et al.³⁹39 Mori ME, Silva FH, Beck FL. Comunidade Ampliada de Pesquisa (CAP) como dispositivo de cogestão: uma aposta no plano coletivo. Interface (Botucatu) 2009; 13 (Supl. 1):719-727. point out, The devices are not ready-made ‘things’ that are implemented in particular services without analyzing the forms of organization that work processes have produced (p.724).

In addition, many of the articles highlight that managers’ support is fundamental. It is certainly important, but in a sense, the need for such support reveals a paradox or limitation of this method, since in practice, co-management, which ultimately aims to foster protagonism, autonomy and democratic relations, is seen to require, above all, the consent of those higher up the hierarchy. It is as if the model is only able to achieve a controlled transformation that maintains the logic it seeks to transform. Or is it the vicissitudes of practice in everyday contradictions that create these constraints?

Although most of the articles mention that there was positive change, such as increased participation, improvement in work processes etc, the studies appear to lack empirical evidence demonstrating that there was concrete change. One of the aims of this analysis was to propose reflections that invite scholars and professionals to think about other possibilities that go beyond those recommended in the reference guide. In this regard, we raise the following questions: Based on the history of participatory management models, what other methodologies could be effective? What can be done to develop participatory management considering that the simple creation of spaces does not ensure participation?

The articles analyzed by this review highlight a number of challenges to applying the devices recommended in the NHP reference guide, including staff resistance and lack of time, human and physical resources, and adequate training, etc. However, the findings show that little mention is made of what is lost or the limits in adopting the participatory model recommended in combination with co-management, or what are the limits imposed by the context and current capitalist culture.

With regard to the theoretical perspectives of co-management, our findings show that all of the frames of reference used by the studies, except ergology, appeared in Campos’ work¹1 Campos GWS. Um método para análise e co-gestão de Coletivos. 3a ed. São Paulo: Hucitec; 2007.. While on the one hand it is logical that that these studies should be framed within the theoretical bases that underpin the guide, on the other, this can be seen as a limitation, meaning that the proposal ends up being reified into a value, something that is good in itself, excluding other existing and previous models.

The findings therefore show that, in practical terms, the model has been adopted as yet another completion of steps and application of strategies and techniques to build collective spaces. Few studies have explored the relational processes in these spaces or limitations of these devices in practice. Further studies are therefore important to identify new proposals and practices that can complement co-management.

Final considerations

Our findings show that a large part of the articles intersect with the work of the author who created the circle method¹1 Campos GWS. Um método para análise e co-gestão de Coletivos. 3a ed. São Paulo: Hucitec; 2007., which seeks to foster relational spaces for management. All the theoretical perspectives used by the studies, except ergology, are present in the work of Campos¹1 Campos GWS. Um método para análise e co-gestão de Coletivos. 3a ed. São Paulo: Hucitec; 2007.. The practical experiences reported by the articles reveal that services are seeking to implement collective spaces. Most of the devices recommended by the NHP are mentioned in the articles, together with other collective spaces created with different names but the same function.

However, with regard to the relational method, which takes into account other aspects beyond administrative planning, the studies tend to focus on technical aspects, paying little attention to communication processes and the relational construction of these spaces. Although there is some discussion of these aspects, the articles fail to delve deeper into the theories or methodologies that underpin the relational practices for the construction of co-management.

It is worth highlighting that the sample of articles does not necessarily represent how co-management is being implemented across different contexts in Brazil. Furthermore, the analysis was based on the construction of meanings drawn from the readings performed by the authors of the current article, meaning that it involved the signification of the articles with a specific objective, not necessarily corresponding to the original intentions or ideas of the authors.

One of the limitations of the study is that we did not expand our search beyond the articles found on the databases. In this regard, the article references provide another source of publications on the topic of concern. However, these publications were not included because we conducted an integrative literature review. In addition, our analysis of the practical experiences was based on the reports of the practices and not the practices themselves, given that we were not present to analyze what took place in the settings reported by the studies.

Finally, throughout this article we have sought to propose reflections and raise questions that act as ideas or directions for future studies on this topic that could give rise to innovative analyses or management theories. We also hope that the reflections proposed by this study serve to draw attention to the need to explore and report other local experiences, thus facilitating access to developments in the everyday practice in local settings.

Acknowledgements

We are grateful to the Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP).

References

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