Abstract

This study aims to discuss the use of planning and programming of actions for the sanitary control of Health Surveillance in health services in Brazilian states, from the perspective of managers and consultation with health plans. Qualitative approach study carried out based on ten interviews with managers of state Health Surveillance, available in a research database financed by the National Council for Scientific and Technological Development, and in health plans with free access on the institutional websites of the respective states. The results showed conceptions about planning, from the programming of actions, integrated planning, definition and achievement of goals to the practice of planning. Some management instruments were also mentioned, such as state health plans and quarterly reports. The analysis of state health plans showed the still scarce approach to guidelines, goals and indicators specifically aimed at Health Surveillance. It was possible to identify that planning, although more focused on programming activities, is present in the work process of state Health Surveillance teams, and its approach is still little mentioned in state health plans.

Keywords:
Health Surveillance; Health Planning Sanitary Control

Introduction

Planning is understood as a process of rationalization of human actions, while seeking to build feasibility and determine propositions in order to solve problems and meet individual and collective needs (Teixeira, 2010TEIXEIRA, C. F. (org.). Enfoques teóricos-metodológicos do planejamento em saúde. Planejamento em Saúde: Conceitos, Métodos e Experiências. Salvador: EDUFBA, 2010.).

In the area of health, planning emerged in the 1960s in Latin America, influenced by the Developmental Theory of the Economic Commission for Latin America and the Caribbean (ECLAC), which preached the idea of redistribution through rational design and social policies (Costa; Pinho; Garcia, 2016COSTA, A. C. M. et al. Processo de trabalho e planejamento em saúde. São Luís: EDUFMA, 2016. (Cadernos de Saúde Toda Família). Disponível em: https://ares.unasus.gov.br/acervo/html/ARES/7463/1/Livro%203%20-%20Processo%20de%20trabalho%20e%20planejamento%20em%20sa%c3%bade.pdf. Acesso em: 21 fev. 2021.
https://ares.unasus.gov.br/acervo/html/A... ). In Brazil, health planning actions arise with legal and normative frameworks of the Unified Health System (SUS), namely: Federal Constitution of 1988 and the Organic Health Law number 8.080/1990 (Costa; Pinho; Garcia, 2016). According to the aforementioned law, in its "Chapter III - Planning and Budget", Art.36, the SUS planning and budgeting process must be upward, from the local to the federal level. Also according to the law, in "Section II - Competence" it is up to the national direction of SUS to prepare the Strategic Planning in technical cooperation with states, municipalities and the Federal District (Brasil, 2020).

Subsequently, with Decree number 7,508, of June 28, 2011, which provides for the organization of the SUS, health planning, health care and inter-federative articulation and other measures, health planning again gained prominence, becoming a mandatory element for public entities, as provided for in chapter III - Health Planning, Art. 15, §1 (Brasil, 2020).

Linked to this, the complexity of the increasingly growing work process, a consequence of the changes that occurred in the living and health conditions of the population, also gave rise to the interest in health planning that was initially shown through health campaigns and disease control programs (Teixeira, 2010TEIXEIRA, C. F. (org.). Enfoques teóricos-metodológicos do planejamento em saúde. Planejamento em Saúde: Conceitos, Métodos e Experiências. Salvador: EDUFBA, 2010.).

In the field of health surveillance, it is known that the programming of its actions integrates the planning defined by SUS and must be organized based on priority actions related to national indicators or priorities and in accordance with epidemiological criteria and to strengthen health surveillance systems (Ferreira; Silva; Miyashiro, 2017FERREIRA, S. C. C.; SILVA, L. B. da; MIYASHIRO, G. M. Técnico em vigilância em saúde: fundamentos. Rio de Janeiro, 2017. Disponível em: https://www.arca.fiocruz.br/bitstream/icict/39910/2/T%c3%a9cnico%20de%20Vigil%c3%a2ncia%20em%20Sa%c3%bade%20v.2%20-%20Planejamento%20em%20sa%c3%bade.pdf. Acesso em: 07 maio 2020.
https://www.arca.fiocruz.br/bitstream/ic... ).

As for health surveillance actions, they consist of processes and practices that involve, in a transversal way, the following components: Epidemiological Surveillance, Occupational Health, Environmental Health Surveillance and Health Surveillance (CNS, 2018). Opening a range for Health Surveillance, it is known that it has a multiprofessional and institutional nature and its actions are based on risk prevention and control, as well as health protection and promotion (Costa, 2009COSTA, E. A. (org.). Vigilância sanitária: temas para debate. Salvador: EDUFBA, 2009. Disponível em: https://static.scielo.org/scielobooks/6bmrk/pdf/costa-9788523208813.pdf. Acesso em: 23 maio 2020.
https://static.scielo.org/scielobooks/6b... ).

According to Law number 8.080/1990, the Health Surveillance is described as

In the context of health services, it is noted that Health Surveillance acts in an essential way, through on-site actions aimed at the good operating conditions of health facilities, as well as the protection of individual and collective health through the verification and identification of potential sources of damage (Silva; Molesini, 2016SILVA, G. T. R.; MOLESINI, J. A. O. II Seminário de gestão contemporânea de sistemas de saúde: a tríade qualidade, acreditação e segurança do paciente. Revista Baiana de Saúde Pública. Salvador, v. 40, sup., p. 9-13, 2016. Disponível em: https://rbsp.sesab.ba.gov.br/index.php/rbsp/article/view/2663/1814. Acesso em: 26 maio 2020.
https://rbsp.sesab.ba.gov.br/index.php/r... ). However, there is a certain scarcity on the registration of planning actions within this service as a powerful tool to enable its work process with regard to sanitary control. Based on the database built by Capelato (2019), with publications on Health Surveillance in Health Services selected from Scielo and Lilacs, it was possible to identify studies related to management, organization and evaluation, published from 2009 to 2013, but they do not bring about planning, especially aimed at sanitary control in health services. In search of studies focused on Health Surveillance planning, we found one that deals with methods and structures that make up the planning of Health Surveillance, pointing out the process as essential for achieving results, as well as influencing the improvement of the performance of institutions (Flexa , 2017FLEXA, R. G. C. et al. Planejamento estratégico em vigilância sanitária: aplicação do balanced scored (BSC). Vigilância Sanitária em Debate: Sociedade, Ciência e Tecnologia, v. 5, n. 2, 2017. Disponível em: https://www.redalyc.org/journal/5705/570562894003/570562894003.pdf. Acesso em: 21 dez. 2021.
https://www.redalyc.org/journal/5705/570... ), and another that reinforces the idea of the need for a critical analysis of this process when it comes to Health Surveillance actions and services (Oliveira; Dallarei, 2014OLIVEIRA, A. M. C.; DELLARI, S. G. Participação social no planejamento das ações e serviços de vigilância sanitária: uma análise crítica. Revista VISA em Debate: Sociedade, Ciência e Tecnologia. Rio de Janeiro, v. 2, n. 2, 2014. Disponível em: https://visaemdebate.incqs.fiocruz.br/index.php/visaemdebate/article/view/181/123. Acesso em: 21 dez. 2021.
https://visaemdebate.incqs.fiocruz.br/in... ).

For Silva, Costa and Lucchese (2018SILVA, J. A. A. da; COSTA, E. A.; LUCCHESE, G. SUS 30 anos: vigilância sanitária. Ciência e Saúde Coletiva. Rio de Janeiro, v. 23, n. 6, p. 1953-1962, 2018. Disponível em: https://www.scielo.br/pdf/csc/v23n6/1413-8123-csc-23-06-1953.pdf. Acesso em: 23 maio 2020.
https://www.scielo.br/pdf/csc/v23n6/1413... ), only recently has the theme of Health Surveillance become frequent in research and teaching in the country, a fact that is also associated with the recent understanding of its importance in the socio-cultural and economic fields. In addition, there are still few studies on planning in the Health Surveillance. Thus, in view of this gap, the following questions are presented for this study: how has the planning and/or programming of actions been used for the sanitary control of health services? How have state health plans been addressing and/or considering Health Surveillance in their elaboration process? Therefore, the objective is to discuss the use of planning and programming of actions for the sanitary control of Health Surveillance in health services in Brazilian states, from the perspective of managers and consultation with health plans.

Methodological strategies

This qualitative study is part of a broader research entitled “Health Surveillance in Primary Care and Specialized Care health services in Brazilian states” (Souza , 2018SOUZA, M. K. B. de et al. Vigilância sanitária nos serviços de saúde da atenção básica e atenção especializada em estados brasileiros. Salvador: ISC/UFBa, 2018.), funded by the National Council for Scientific and Technological Development (CNPQ), Universal Notice MCTIC/CNPq number 28/2018, and approved by the Research Ethics Committee of the Institute of Collective Health of the Federal University of Bahia (CEP/ISC/UFBA). According to opinions, version 2 and 5, the latter includes the specificity of the objective on planning and programming, number 3,423,630 and 4,420,180 respectively.

To discuss the use of planning and programming of actions for the sanitary control of Health Surveillance in health services in Brazilian states, the records available in the database of interviews with state surveillance managers were used (Souza , 2018SOUZA, M. K. B. de et al. Vigilância sanitária nos serviços de saúde da atenção básica e atenção especializada em estados brasileiros. Salvador: ISC/UFBa, 2018.).

From the set of questions answered by managers of the Health Surveillance of ten Brazilian states, from the five Brazilian regions, interviewed from November 2019 to July 2020, we proceeded to the content analysis Minayo . (2001MINAYO, M. C. de S. et al. Pesquisa social: teoria, método e criatividade. Petrópolis: Vozes, 2001.) of the answers to the question about how the planning and programming of the actions of the State Health Surveillance aimed at the sanitary control of health services are carried out. Therefore, the analysis of the information provided during the interviews fulfilled the following stages, according to Minayo et al. (2001): the reading of the transcribed content made available; the exploration of the material and problematization of the findings; and the treatment and interpretation based on the references used for the preparation of the article.

It should be noted that all ethical principles were respected. Respondents are indicated by the letter I (state/interview) and sequential number (I1, I2, E3... I10) and all signed the Informed Consent Form (ICF) after agreeing to participate freely in the study.

In addition to the interviews, the analysis of the state health plans was also carried out, which were accessed from the institutional websites of the secretariats of the respective states. The documentary analysis of the state health plans 2016-2019 of the ten states included considered the criteria for their elaboration according to the National Council of Health Secretaries (CONASS, 2015), as well as the needs of the population, namely: situational analysis; definition of guidelines, objectives, goals and indicators; and monitoring and evaluation process. In addition, they should also consider the guidelines defined by the Health Councils and Health Conferences. Thus, a comparative table was prepared based on the content extracted from state health plans, considering such criteria in order to identify how these instruments have been approaching and/or considering the Health Surveillance.

Results and Discussion

The findings obtained from the interviews and plans are described and organized according to the following categories: Conceptions of planning for health surveillance in health services; Strategies for Health Surveillance planning; Annual schedule as an instrument for Health Surveillance; and Other planning instruments for Health Surveillance. For each category, the discussion follows.

Planning conceptions for the performance of Health Surveillance in health services

The records of the interviews revealed different conceptions about planning: planning reduced to action programming; integrated planning; definition and achievement of goals as a planning practice, as shown in Board 2 below:

One of the conceptions identified from the records of the interviews was the planning reduced to the programming of actions. The act of planning is a permanent process, carried out in order to direct the actions developed to achieve the objectives; in other words, it requires thinking before acting, so it has a systematic character articulating immediate actions and future actions (Faria; Campos; Santos, 2018FARIA, H. P. de; CAMPOS, F. C. de; SANTOS, M. A. Planejamento, avaliação e programação das ações de saúde. Belo Horizonte: NESCON / UFMG, 2018. Disponível em: https://ares.unasus.gov.br/acervo/html/ARES/13689/1/PLANEJAMENTO_AVALIACAO_PROGRAMACAO_Versao_Final.pdf. Acesso: em 15 out. 2020.
https://ares.unasus.gov.br/acervo/html/A... ). Regarding programming, this is configured as a planning-related stage that also requires the use of appropriate materials and methods in order to favor its viability (Jaramillo, 2015JARAMILLO, N. M. Uso racional de medicamentos em condutas terapêuticas e nos macroprocessos da assistência farmacêutica. Revista Organização Pan-Americana da Saúde. Brasília, 2015. Disponível: 002uso_rmprefacio_urm_2_1.pdf (fiocruz.br). Acesso em: 03 fev. 2021.).

The planning and programming of the actions of the Health Surveillance require the understanding of the agents involved so that this relationship aims to control health risks through the organization and solidary management between them (Leal; Teixeira, 2017LEAL, C. O. B. S.; TEIXEIRA, C. F. de S. Solidariedade: uma perspectiva inovadora na gestão e organização das ações de vigilância sanitária. Revista Ciência e Saúde Coletiva. Rio de Janeiro, v. 22, n. 10, 2017. Disponível em: https://www.scielosp.org/article/csc/2017.v22n10/3161-3172/pt/. Acesso em: 27 out. 2020.
https://www.scielosp.org/article/csc/201... ).

Conception about integrated planning was also identified in the interview records, evidencing the relationship with the State Department of Health, with the health regions (regional centers or boards) and with/between services of different levels of care or organization.

According to Costa . (2016COSTA, A. C. M. et al. Processo de trabalho e planejamento em saúde. São Luís: EDUFMA, 2016. (Cadernos de Saúde Toda Família). Disponível em: https://ares.unasus.gov.br/acervo/html/ARES/7463/1/Livro%203%20-%20Processo%20de%20trabalho%20e%20planejamento%20em%20sa%c3%bade.pdf. Acesso em: 21 fev. 2021.
https://ares.unasus.gov.br/acervo/html/A... ), integrated planning is directly linked to the realization of comprehensive care, so it is necessary that the various levels of management articulate themselves in an intersectoral way to reorganize their work processes with a view to achieving actions aimed at promotion, prevention and rehabilitation.

Regarding regional planning, Decree number 7,508, of July 28, 2011, which regulates Law number 8,080, of September 19, 1990, states that it must be done in a regionalized manner, considering the needs of municipalities, as well as the establishment of health goals (Brasil, 2020). Thus, it should be understood as a relevant alternative with regard to upward planning in SUS in order to strengthen it (Mendes, 2016MENDES, V. A. do P. Estudo sobre planejamento regional nos estados brasileiros. 2016. Dissertação (Mestrado em Saúde Coletiva) - Universidade de Brasília. Brasília-DF, 2016. Disponível em 2016_VitorÁtiladoPradoMendes.pdf (unb.br). Acesso em: 20 fev. 2021.). And the organization of the SUS, through regional planning, expresses, in addition to health priorities, the inherent responsibilities among the various managers that make up the health regions (Brasil, 2016). Although regional planning has advanced, many of the decisions made in these spaces are more political than technical, often with an individualized behavior, since it is also related to the few monitoring actions aimed at health services, which directly affects the control processes, as well as negotiation (Medeiros ., 2020MEDEIROS, A. V. C. et al. Gestão da qualidade nos serviços de hemoterapia do interior do Rio Grande Do Norte: análise dos efeitos de um ciclo de melhoria. Revista Visa em Debate-Saúde, Ciência e Tecnologia. Rio de Janeiro, v. 8, n. 4, 2020. Disponível em: https://visaemdebate.incqs.fiocruz.br/index.php/visaemdebate/article/view/1494/1259. Acesso em: 09 jan. 2021.
https://visaemdebate.incqs.fiocruz.br/in... ).

Sales Neto (2016) states that although Health Surveillance is commonly isolated from other health actions, its integration with primary care becomes extremely important, as well as it is also necessary for health sector workers to know the work carried out by both, since it can favor the development of more articulated health actions aimed at solving more complex contexts, as well as knowledge of the health risks existing in the territory. Regarding the importance of such articulation, Amorim . (2017AMORIM, L. de A. et al. Vigilância em saúde do trabalhador na atenção básica: aprendizagens com as equipes de saúde da família de João Pessoa, Paraíba, Brasil. Ciência & Saúde Coletiva, v. 22, n. 10, 2017. Disponível em: https://www.scielosp.org/article/csc/2017.v22n10/3403-3413/pt/. Acesso em: 13 jan. 2021.
https://www.scielosp.org/article/csc/201... ) add that the relationship between Primary Care and Health Surveillance is crucial for the integrality of care, including between the various points of the network, especially with Health, Environmental and Epidemiological Surveillance.

Another conception presented by the interviewees was the definition and achievement of goals as a planning practice. For Araújo and Biz (2016ARAÚJO, E. S. de; BIZ, M. C. P. O planejamento em saúde na prática. Revista Científica CIF Brasil, v. 5, p. 5, 2016. Disponível em: https://www.researchgate.net/profile/Eduardo-Cordeiro-3/publication/307608727_O_PLANEJAMENTO_EM_SAUDE_NA_PRATICA_Practices_for_planning_Health_Sector/links/57cd75ad08aed67896ffb64c/O-PLANEJAMENTO-EM-SAUDE-NA-PRATICA-Practices-for-planning-Health-Sector.pdf. Acesso em: 09 jan. 2021.
https://www.researchgate.net/profile/Edu... ), the establishment of goals and the formulation of plans to achieve them are part of the process of any planning. However, among the activities involved in the elaboration of health planning, the elaboration of a prior situational diagnosis must be considered in order to identify the health conditions of the population, thus constituting an aid tool.

It should be noted that planning cannot be understood only as a simple method of projecting goals, it needs to be understood in its strategic essence in order to redirect projects and programs in order to contribute to the improvement of SUS management, in addition to being closely related to monitoring and evaluation processes (Brasil, 2016).

Thus, it is important to define a form of planning, whatever it may be, in order to direct the actions to be carried out, as well as the achievement of the proposed objectives, which is supported by an understandable language with regard to basic concepts, terminologies and instruments used (Farias; Campos; Santos, 2018FARIA, H. P. de; CAMPOS, F. C. de; SANTOS, M. A. Planejamento, avaliação e programação das ações de saúde. Belo Horizonte: NESCON / UFMG, 2018. Disponível em: https://ares.unasus.gov.br/acervo/html/ARES/13689/1/PLANEJAMENTO_AVALIACAO_PROGRAMACAO_Versao_Final.pdf. Acesso: em 15 out. 2020.
https://ares.unasus.gov.br/acervo/html/A... ).

Strategies for Health Surveillance planning

The interviews brought the planning strategies used by the Health Surveillance teams for the sanitary control of health services: training/qualification activities; continuous contact with the services; creation of a driving group, work commissions, and management committee.

To stimulate and/or strengthen the importance of the use of planning instruments and the programming of Health Surveillance actions in health services, some interviewees mentioned training to promote the training of workers in programming and planning.

Permanent health education (PHE) has as an element of transformation the work process, especially in the field of practices, in the sense of solving problems inherent to the routine of the service, taking as a starting point the critical perception of professionals (Ferreira ., 2019FERREIRA, L. et al. Educação permanente em saúde na atenção primária: uma revisão integrativa da literatura. Rev Saúde em Debate, v. 43, n. 120, 2019. Disponível em:https://www.scielosp.org/article/sdeb/2019.v43n120/223-239/pt/. Acesso em: 21 jan. 2020.
https://www.scielosp.org/article/sdeb/20... ).

In addition to the training offered, strategies for articulation, communication and integration between the sectors to plan, organize and operationalize the actions can be extracted from the reports the continuous contact with the services and the creation of a driving group, work commissions, management committee.

For Chorny, Kuschnir, Taveira (2008CHORNY, A. H.; KUSCHNIR, R.; TAVEIRA, M. Planejamento e programação em saúde: texto para fixação de conteúdos e seminário. Rio de Janeiro: Fiocruz, 2008. Disponível em: http://www.ensp.fiocruz.br/portal-ensp/_uploads/documentos-pessoais/documento-pessoal_12465.pdf>. Acesso em: 21 jan. 2021.
http://www.ensp.fiocruz.br/portal-ensp/_... ), there is no defined method for planning, and this variable is according to who plans, its objectives and the context in which it occurs, and thus several methods can be used, since different objectives lead to different processes. For Farias, Campo, Santos (2018FARIA, H. P. de; CAMPOS, F. C. de; SANTOS, M. A. Planejamento, avaliação e programação das ações de saúde. Belo Horizonte: NESCON / UFMG, 2018. Disponível em: https://ares.unasus.gov.br/acervo/html/ARES/13689/1/PLANEJAMENTO_AVALIACAO_PROGRAMACAO_Versao_Final.pdf. Acesso: em 15 out. 2020.
https://ares.unasus.gov.br/acervo/html/A... ), there are several ways to plan; however, it is necessary to have knowledge in relation to the different forms and methods in order to identify the most viable way to achieve the objectives from the current reality, thus establishing the most appropriate model/method for management.

Annual programming as a tool for Health Surveillance

Concerning the use of Health Plans in the work process of the Health Surveillance, the interviewees report how this instrument has been used in their planning process or not used, being, in this case, replaced by some other method, as mentioned below:

It should be noted that, among the interviewees, with regard to the annual health program, in general elaborated based on the state health plan, this, as an instrument for the process of planning and programming of actions, was mentioned only by one of the ten interviewees. The others reported having an "annual planning" for the development of their actions, which presupposes the disposition and organization of actions based on demands and routines.

Ferreira . (2018FERREIRA, J. et al. Planejamento regional dos serviços de saúde: o que dizem os gestores. Saúde e Sociedade. São Paulo, v. 27, n. 1, 2018. Disponível em: https://www.scielosp.org/article/sausoc/2018.v27n1/69-79/pt/. Acesso em: 19 fev. 2021.
https://www.scielosp.org/article/sausoc/... ) show that many managers working in SUS do not know the management documents, which negatively affects the implementation of actions, which sometimes does not correspond to what is actually recommended in the document. Therefore, there is incipience in relation to theory and practice, making planning becomes something normative, being carried out in a precarious way only for the purpose of obtaining financial resources.

In addition, the findings obtained from the State Health Plans analyzed add to the planning and programming of Health Surveillance actions. The following table presents specific content of the Health Surveillance addressed on the situational analysis, the definition of guidelines, objectives, goals and indicators and the monitoring and evaluation process, considered essential criteria, according to Conass (2015).

When analyzing the box above, it appears that, in the process of preparing the plans, some components are essential in their composition and, based on this, it was possible to perceive the inclusion (or not) of the Health Surveillance in the planning and programming process of state health actions.

Based on the Situational Analysis component, it is included in only five state plans, which may reflect a lack of interest or simply not prioritizing Health Surveillance within the context of state health planning, since the situational analysis seeks to generate relevant information that will direct health actions and decision-making processes at various levels of care (Brasil, 2015). In addition, such information contributes to a better understanding of the problems and needs of the population, since they tend to show their health profile, thus configuring a powerful tool for health planning (Vasconcelos; Garcia, 2016VASCONCELOS, J. P. R.; GARCIA, R. A. V. Análise da situação de saúde de águas lindas de Goiás: o desafio do planejamento. Revista Eletrônica Gestão e Saúde. Brasília, v 7, n. 3, p. 1173-90, 2016. Disponível em:https://periodicos.unb.br/index.php/rgs/article/view/3629/3308. Acesso em: 23 jan. 2021.
https://periodicos.unb.br/index.php/rgs/... ).

Regarding the components, in relation to the guidelines, none of the states analyzed addresses this element in a specific way, and these are defined in such documents from the seven axes of the 15^th National Conference on Health (NCH, 2015): Right to Health, Guarantee of Access and Quality Care; Social Participation and Control; Valorization of Work and Health Education; Financing of SUS and Public-Private Relations; Management of SUS and Health Care Models; Information, Education and Communication Policy of SUS; Science, Technology and Innovation in SUS, Democratic and Popular Reforms of the State (P1, P8, P4 and P2).

Some plans, on the other hand, have more specific guidelines, not necessarily presenting a direct link with the aforementioned NCH axes (P7, P9, P5 and P10). In other contexts, the guidelines are not cited, giving way to other terminologies, such as commitment (P3) and axes (P6). Regarding the objectives, only four plans (P3, P4, P6 and P10) portray them more related to Health Surveillance, addressing issues related to the sector's work process, such as the surveillance of health products and services, and ensuring improvement of actions that qualify their processes; while the others address the objectives in a more general context of health surveillance.

Regarding the definition of goals, these were considered in most of the plans analyzed, some bringing more specific goals on Health Surveillance, and only one establishing them in a more comprehensive context of health surveillance (P3). This fact is in line with the specifications of the National Council of Health Secretaries (2015), which states that plans should be prepared considering, in addition to the needs of the population, the following criteria: situational analysis; definition of guidelines, objectives, goals and indicators; and monitoring and evaluation process. Consideration should also be given to the guidelines set by the Health Councils and Health Conferences.

With regard to monitoring and evaluation, these elements are included in most of the plans analyzed. Faria, Campos, Santos (2018FARIA, H. P. de; CAMPOS, F. C. de; SANTOS, M. A. Planejamento, avaliação e programação das ações de saúde. Belo Horizonte: NESCON / UFMG, 2018. Disponível em: https://ares.unasus.gov.br/acervo/html/ARES/13689/1/PLANEJAMENTO_AVALIACAO_PROGRAMACAO_Versao_Final.pdf. Acesso: em 15 out. 2020.
https://ares.unasus.gov.br/acervo/html/A... ) report that evaluation, even if it is a more momentary activity, has been increasingly relevant, since it is directly related to the generation of knowledge and the issuance of value judgments, in addition to contributing to planning actions and decision-making processes. In addition, it provides, when necessary, adjustments in the processes in a strategic way so that the intended objectives are achieved. Monitoring, although it has a similar purpose to evaluation, has a continuous and permanent character, since it tends to happen for a longer period. However, it is known that both contribute to improvement and quality of service.

Regarding the indicators specifically aimed at actions developed by the Health Surveillance, it is clear that these are addressed in only four of the ten plans (P1, P3, P4 and P10). Regarding the other states analyzed (P7 and P5), they address indicators in their documents, but there is no direct relationship with the Health Surveillance, while P8, P9, P6 and P2 do not present indicators in their plans, which signals the lack of definition and priority in the process of evaluation and monitoring of actions in most states.

The indicators reflect the sanitary conditions of a population, in addition to contributing to the surveillance of health conditions. Developed with the objective of quantifying and evaluating information, the indicators must be of quality directly related to the properties of the components addressed in their construction, as well as the information systems used. Therefore, it is expected that an indicator should be easily interpreted and analyzed by managers, administrators and users of information (RIPSA, 2008), as well as it should be constantly reassessed so that it can fit within the reality of Health Surveillance in order to actually show the effectiveness of its work process in health services (Maia; Guilhem, 2016MAIA, C.; GUILHEM, D. A regulação sanitária brasileira como parte da política de saúde: lacunas e desafios. Revista Panamericana de Salud Publica, v. 39 , n. 5, 2016. Disponível em: https://www.scielosp.org/article/rpsp/2016.v39n5/226-231/pt/#. Acesso em: 15 out. 2020.
https://www.scielosp.org/article/rpsp/20... ).

For Martins . (2020MARTINS, M. A. F. et al. Indicadores para avaliação das ações da vigilância sanitária: uma revisão narrativa da literatura. Revista Visa em Debate - Saúde, Sociedade e Tecnologia. Rio de janeiro, v. 8, n. 4, 2020. Disponível em: https://visaemdebate.incqs.fiocruz.br/index.php/visaemdebate/article/view/1590/1269 Acesso em: 22 jan. 2021.
https://visaemdebate.incqs.fiocruz.br/in... ), the work process within Health Surveillance is strengthened as indicators are constructed with a view to effectively monitoring its actions, constituting fundamental elements that support decision-making.

Other planning instruments for Health Surveillance

Regarding the use of other planning instruments, the quarterly reports, annual programming and even the existence of agreements as a means for the programming of actions for Health Surveillance were mentioned.

Ordinance number 2,135, of September 25, 2013, which establishes guidelines for the planning process within the scope of the Unified Health System (SUS) in its article 1, sole paragraph, states that one of its assumptions is the compatibility between its instruments, namely: health plan, a central element that directs the process, as well as its respective annual schedules that, in turn, operationalize the intentions contained in the document; finally, the management reports that present the results obtained with the actions of the annual schedule, among others (Brasil, 2020).

Regarding the instruments used in SUS management, it is necessary to understand that they need to be related in order to integrate a cyclical planning process to favor managers in their practices, in addition to promoting the operationalization of SUS in an integrated way (Brasil, 2016). Therefore, when the manager knows the management tools and participates in the process of preparing them, an important development is perceived, in a more advanced way, of his management function (Pinafo ., 2016PINAFO, E. et al. Gestão do SUS em município de pequeno porte no estado do Paraná: perfil, funções e conhecimento de gestão. Espaço Para a Saúde-Revista de Saúde Pública do Paraná. Londrina, v. 17, n. 1, 2016. Disponível em:http://espacoparasaude.fpp.edu.br/index.php/espacosaude/article/view/377/21. Acesso em: 22 fev. 2021.
http://espacoparasaude.fpp.edu.br/index.... ).

In the context of Health Surveillance, as it is consolidated, the use of techniques and instruments that are part of its routine has also advanced. Therefore, the use of these for health control purposes in health services, among which are included material instruments, as well as technical and legal standards, all prerequisites for their performance, not only integrates the work process of this service, but also constitutes a prerequisite for its performance (Oliveira; Ianni, 2018OLIVEIRA, A. M. C.; IANNI, A. M. Z. Caminhos para vigilância sanitária: o desafio da fiscalização nos serviços de saúde. Revista Visa em Debate - Saúde, Sociedade e Tecnologia. Rio de Janeiro, v. 6, p. 3, 2018. Disponível em: https://visaemdebate.incqs.fiocruz.br/index.php/visaemdebate/article/view/1114/489. Acesso em: 21 jan. 2021.
https://visaemdebate.incqs.fiocruz.br/in... ).

Final Considerations

Considering that Health Surveillance is part of the scope of action of health surveillance and, therefore, of SUS, its actions should not be developed in isolation, but articulated and integrated with the network. The set of interviews and state health plans analyzed here present elements focused on various services, such as primary, medium and high complexity care, pharmaceutical care and health surveillance.

The findings on planning and programming of actions, based on the study that addressed Health Surveillance in Primary Care and Specialized Care health services, showed the sanitary control of health services in general and, therefore, the object of surveillance action, although some particularities can be reflected to meet the specificities of services in their different levels of complexity and technological density. In addition, the documentary analysis showed, from the state health plans, the definition of actions, goals and indicators related to Health Surveillance.

As for health surveillance, such an approach, more comprehensive and within the scope of the health system and services, seems to justify the absence of specific goals for Health Surveillance in such documents.

The state plans analyzed meet a predefined structure, and the content of actions aimed at Health Surveillance may have been compromised by the broad approach brought by health surveillance or by being on the margins of other health services, negatively impacting its process of (re)affirmation as an essential activity that also aims at promotion and prevention actions, in addition to health protection.

Therefore, health plans as SUS management instruments must have defined objectives and goals for health, including actions and services, in which it is important to highlight their importance for the guidance of decision making by managers.

This study highlighted the planning and programming for Health Surveillance and also different conceptions and strategies from the perspective of managers. It was found that planning, although more focused on programming activities, is present in the work process of state Health Surveillance, which is developed according to each reality, although it has been little addressed in state health plans.

It is known that there is no delimited way to plan, which is flexible, changeable over time and according to the needs to be remedied and the objectives to be achieved. Thus, in the case of strategies adopted for planning, various conceptions and different methods used by managers are observed.

Acknowledgements

To the National Council for Scientific and Technological Development - CNPq, for the financing of this study, through Universal Notice MCTIC/CNPq number 28/2018.

References

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