Abstract

The guidelines of Decree No. 7508 - June 28, 2011 - have contributed to enhance the capacity of governance of small municipalities in health regions. The objective of this study was to identify the potential and the obstacles in the process of integrated regional planning in health region 29, Rio Grande do Sul. This is a case study carried out through information from semi-structured interviews, field observations, and documentary records, analyzed according to Content Analysis method. The study had participation of health managers of five municipalities and three state public servants linked to the 16th Regional Health Coordination, selected intentionally. Five categories of analysis emerged: the Regional Intermanagers Committee (CIR) as a space of coordination; the strengthening of the Brazilian Unified Health System; the weakness of the management; individualism in observing the process; and what has guided the meetings of the CIR. Results indicate that the integrated regional planning process has advanced, in the sense of CIR being constituted as a space of mutual support between the municipal and state management. However, decisions are made with more political than technical basis, with little monitoring of the access to health actions and health services, hindering the ability of control and negotiation in relation to service providers. It is considered that the CIR needs to be strengthened and consolidated through improvement of the management and through effective participation of state and municipal health managers in order to enable regional governance.

Keywords:
Health Planning; Health Management; Regionalization; Public Health Policies

Introduction

Regionalization has become a guideline of difficult implementation in the context of the Brazilian Unified Health System (SUS), since it requires a supportive stance between the federal entities. The legal framework of SUS was insufficient for the effective institution of regionalization of health throughout Brazil. According to (Viana, Lima, and Ferreira, 2010VIANA, A. L. d’Á.; LIMA, L. D.; FERREIRA, M. P. Condicionantes estruturais da regionalização na saúde: tipologia dos colegiados de gestão regional. Ciência & Saúde Coletiva, Rio de Janeiro, v. 15, n. 5, p. 2317-2326, 2010.), the decentralization of SUS brought major advances towards expanding health care coverage, but failed to resolve the huge inequalities in access to and use of these services, especially in the medium complexity, also failing to lead to the formation of more cooperative arrangements in health care.

In this context, Decree No. 7,508 came to reaffirm the regionalization as a strategy for reordering of the health policy, constituting a regulator of the SUS’ organizational structure, health planning, care, and interfederational coordination. It also determines the organization of the regions into health care networks with local and regional management (Brasil, 2011BRASIL. Casa Civil. Subchefia para Assuntos Jurídicos. Decreto nº 7.508, de 28 de junho de 2011. Regulamenta a Lei nº 8.080, de 19 de setembro de 1990, para dispor sobre a organização do Sistema Único de Saúde (SUS), o planejamento da saúde, a assistência à saúde e a articulação interfederativa, e dá outras providências. Diário Oficial da União, Brasília, DF, 29 jun. 2011. Seção 1, p. 1-3.). The advance proposed by the Decree was the wide participation of the municipal management in decision-making through the Regional Intermanagers Committee (CIR) and the Organizational Contract of Public Action (Coap), which determines the integrated and ascendant regional planning. Regionalization is observed in all European countries with national health System (NHS), structured based on territorial and populational planning and health regions that work in levels of complexity, and their most important characteristic is that they are based on Primary Health Care (Freire, 2006FREIRE, J. M. El sistema nacional de salud español en perspectiva comparada europea: diferencias, similitudes, retos y opciones. Claridad - Sanidad, Madrid, v. 1, p. 31-45, jul.-set. 2006.). In this case, it should be noted differences in relation to the existence of political and administrative autonomy that occurs in the regional structures of some countries.

Research conducted in the United States (USA) suggests a regional approach to health care. In this sense, regional structures must be capable of providing at least 60% or more of the essential health services to the population. The main justification consists in sharing resources, working with regional demands, and ensuring consistency between regional, state, and federal planning (Stoto, 2008STOTO, M. A. Regionalization in local public health systems: variation in rationale, implementation, and impact on public health preparedness. Public Health Reports, Thousand Oaks, v. 123, n. 4, p. 441-449, 2008.).

After Decree No. 7,508/2011, the state of Rio Grande do Sul was reorganized into 30 health regions, in 2012. Region 29, named Valleys and Mountains, consists of 27 municipalities, 209,144 inhabitants (IBGE, 2010IBGE - INSTITUTO BRASILEIRO DE GEOGRAFIA E ESTATÍSTICA. Censo Demográfico 2010. 2010. Disponível em: <Disponível em: https://goo.gl/F5Msw4 >. Acesso em: 12 nov. 2014.
https://goo.gl/F5Msw4... ), and is linked to administrative region of the 16th Regional Health Coordination (CRS). Of the 27 municipalities that compose the region, nineteen have 100% coverage from the Family Health Strategy (FHS) (Brasil, 2013bBRASIL. Ministério da Saúde. Departamento de Atenção Básica. Nota Técnica. 2013b. Disponível em: <Disponível em: http://189.28.128.100/dab/docs/geral/historico_cobertura_sf_nota_tecnica.pdf >. Acesso em: 11 nov. 2014.
http://189.28.128.100/dab/docs/geral/his... ). The average population in the region is 7,702.33 inhabitants, and the largest municipality has 71,445 inhabitants. The geographic location of the municipalities is represented in Figure 1.

The integrated regional planning establishes the CIR as a space of coordination and agreement between the federal entities, enabling discussions to propose operational, financial, and administrative aspects of the shared management of SUS (Brasil, 2011BRASIL. Casa Civil. Subchefia para Assuntos Jurídicos. Decreto nº 7.508, de 28 de junho de 2011. Regulamenta a Lei nº 8.080, de 19 de setembro de 1990, para dispor sobre a organização do Sistema Único de Saúde (SUS), o planejamento da saúde, a assistência à saúde e a articulação interfederativa, e dá outras providências. Diário Oficial da União, Brasília, DF, 29 jun. 2011. Seção 1, p. 1-3.). In Region 29, in addition to the 27 municipal managers, there is participation of five representatives of the state management, composing an arena of 32 actors. The CIR has the importance of consolidating the public policies concerning health care and, considering that regionalization is key in this sphere, it has a key role in this process, as this is the space where the organization of a region’s health management and health care will be planned, as well as the financial resources for this purpose will be defined.

In the 1990s, deployment of the SUS in Region 29 coincided with the process of creating many municipalities with low populational density, few technoassistential resources, and consequent external dependency. Decentralized health systems are quite heterogeneous in the country, and their results are very dependent on prior local conditions, making the organization of regional health systems complex and requiring the strengthening of their governance spaces (Viana, 2015VIANA, A. L. d’Á. et al. Tipologia das regiões de saúde: condicionantes estruturais para a regionalização no Brasil. Saúde & Sociedade, São Paulo, v. 24, n. 2, p. 413-422, 2015.). The context observed in this region is similar to others in the country, considering that about 70% of Brazilian municipalities have less than 15,000 inhabitants. Thus, it is understood that the results of this study may eventually be observed in other health regions of the country.

Similarly to the processes observed after the Pact for Management, in which according to (Machado, 2009MACHADO, J. A. Pacto de gestão na saúde: até onde esperar uma “regionalização solidária e cooperativa”? Revista Brasileira de Ciências Sociais, São Paulo, v. 24, n. 71, p. 105-193, 2009., p. 116) “there is a set of signs of weak institutional guarantees that the ‘cooperative and solidary regionalization’ is to be incorporated into the reciprocal expectations of the SUS managers,” it is questioned if Decree No. 7,508 (Brasil, 2011BRASIL. Casa Civil. Subchefia para Assuntos Jurídicos. Decreto nº 7.508, de 28 de junho de 2011. Regulamenta a Lei nº 8.080, de 19 de setembro de 1990, para dispor sobre a organização do Sistema Único de Saúde (SUS), o planejamento da saúde, a assistência à saúde e a articulação interfederativa, e dá outras providências. Diário Oficial da União, Brasília, DF, 29 jun. 2011. Seção 1, p. 1-3.) - which replaced the Pact for Management - has contributed to advance the incorporation of a cooperative and solidarity action and to the managers’ regional governance capacity.

According to (Hufty, Báscolo, and Bazzani, 2006HUFTY, M.; BÁSCOLO E.; BAZZANI, R. Gobernanza en salud: un aporte conceptual y analítico para la investigación. Cadernos de Saúde Pública, Rio de Janeiro, n. 22, p. S35-S45, 2006. Suplemento.), governance is an analytical tool for understanding collective action processes that organize the interaction between actors, the dynamics and rules of a society’s decision-making and implementation processes. (Mendes, 2014MENDES, E. V. Comentários sobre as redes de atenção à saúde no SUS. Revista Divulgação em Saúde para Debate, Rio de Janeiro, n. 52, p. 38-49, 2014.) states that this concept must be complemented by that of governance of Health Care Networks (RAS), ensuring compliance with the pacts and agreements between the actors, the management of conflicts of interest, and the progressive stabilization of the network.

In this context, it is observed in Region 29 movements of collective construction of the integrated regional planning, permeated by challenges and potential related to the need for approaching political, technical, and administrative differences, in addition to the effort to promote advances in the process of regionalization in health. Historically, the lack of regional planning of health policies compromised their suitability to the multiple realities of the Brazilian territory, and disregarded the role of the state spheres of government (Viana; Lima; Ferreira, 2010VIANA, A. L. d’Á.; LIMA, L. D.; FERREIRA, M. P. Condicionantes estruturais da regionalização na saúde: tipologia dos colegiados de gestão regional. Ciência & Saúde Coletiva, Rio de Janeiro, v. 15, n. 5, p. 2317-2326, 2010.). Therefore, this study aimed to identify the potential and the obstacles in the process of integrated regional health planning in region 29/RS, from the perspective of municipal managers and regional public servants.

Methodology

A case study was conducted by using information from semi-structured interviews with five municipal health managers and three public servants of the CRS, participants of the CIR, which were intentionally selected. We used as inclusion criteria the minimum time of one year in the position and effective participation in the CIR meetings. The interviews sought to determine, in the perception of actors involved in regional planning, what are the potential and obstacles in this process.

We complied with the principles of research ethics, according to Resolution 466, December 12, 2012 (Brasil, 2013aBRASIL. Ministério da Saúde. Conselho Nacional de Saúde. Resolução nº 466, de 12 de dezembro de 2012. Trata de pesquisas em seres humanos e atualiza a Resolução nº 196. Diário Oficial da União, Brasília, DF, 13 jun. 2013a.Seção 1, p. 59.), using the Form of Free and Informed Consent of all participants. The categories that emerged were analyzed according to Content Analysis (Bardin’s 2012BARDIN, L. Análise de conteúdo. São Paulo: Edições 70, 2012.). Additionally, observations were carried out in five CIR 29 meetings, in the period from June to October of 2014. These were recorded in a field journal and used to complement the content analysis of the interviews. Another method used was documentary research, analyzing minutes of CIR meetings, held in 2014 - twelve minutes of ordinary meetings and two of extraordinary meetings. The study was approved by the Research Ethics Committee under Protocol No. 612,126, in 2014.

Respondents were aged 27-54 years. Concerning their training, two public servants are of the area of health care, while one is of the area of business administration, all with post-graduate degrees. Among the municipal managers, three finished high school, while two finished higher education, of which one in the area of health. As for time in municipal management, four had been in the position for one year and eight months, while one for six years. Among the participants that worked in state management, one had been in the position for three years and the other two for fifteen years, of which two had already worked in the area of health before being admitted to the position in state management. The previous experience of the municipal health managers is heterogeneous; three are health professionals, while the other two are public servants in other areas. We used the codes SE for state public servant and GM for municipal manager, followed by the number of the interview, in order to maintain the anonymity of the participants.

Based on content analysis of the interviews, observations, and documentary research, five categories emerged, two relating to potential: (1) the CIR as a space of coordination and (2) Strengthening of the SUS; and three related to obstacles: (1) the weaknesses of the management; (2) what has guided the meetings of the CIR; and (3) individualism in observing the process, presented below.

Results and discussion

The CIR as a space of coordination

The managers pointed out different types of potential of CIR, highlighting the possibility of planning actions in health care for municipalities that compose the health care region. SE1 points out that the CIR becomes powerful in that it allows everyone to participate in the negotiation process, as well as enables the possibility to plan, at the regional level, actions to respond to the demands of health care.

In this sense, the possibility of discussing the operational limits of the municipal management is understood as something positive in the arena of the CIR, both in the technical and in the political aspect. Municipal managers reported that sharing problems and needs with colleagues that work in neighboring municipalities, as well as exchanging experiences, encourages the participation of everyone.

The respondents also made it clear in their reports the importance of the CIR for clarification of doubts in the coordination of health care, where the managers can assist in the understanding of the process due to their previous experiences. SE2 refers to the CIR as “a place of exchange of information, in order to enhance local and regional solutions.”

The technopolitical arena of the regional health management

In this sense, despite being an aspiration of the regional SUS, it is observed that there is still need to improve the solidary integration of the social actors represented in this arena, to the extent that individually they are politically weakened and handicapped in the technical condition of ensuring the completeness of the care.

However, in analyzing the municipal managers’ interviews, there emerged as potential the possibility of being heard, a fact perceived as relevant for the construction of this space, as well as the possibility of integration between the municipalities: “they have their individual point of view and we discuss, sometimes we reach conclusions that get to help the municipalities, we have opportunity and voice there” (GM2).

The municipalities are the actors that carry out the regional health strategies and maintaining their autonomy is essential to the effectiveness of the process, which, otherwise, can be a source of frequent conflicts and reduction of collective potential in the coordination of health care (Ouverney, 2005OUVERNEY, A. M. Regionalização do SUS: uma análise da estratégia de integração intermunicipal. Administração em Diálogo, São Paulo, n. 7, p. 91-106, 2005.). The respondents point out that this space of exchange of dialogue becomes powerful, because it allows for the health teams’ constant learning, resulting in improvement of the region’s health system, constituting a “collective space to analyze the health care” (SE1), and it is based on these meetings that “we reach conclusions that get to help the municipalities” (GM2).

(Miranda, 2010MIRANDA, A. S. Processo decisório em Comissões Intergestores do Sistema Único de Saúde: governabilidade resiliente, integração sistêmica (auto)regulada. Política, Planejamento e Gestão em Saúde, Salvador, v. 1, n. 1, p. 117-139, 2010.) notes that the CIR was created with the aim of meeting “institutional demands, in intergovernmental negotiations, in production of agreements and arrangements mediated by the technobureaucratic discourse.” The meeting is seen as a possible moment for collective coordination of the regional planning, since “many issues also need to be planned and approved regionally and this space ensures that” (SE1).

It is observed that the CIR has favored greater participation of local managers, both from a political and a technical perspective, utilizing the space to coordinate the collective planning of health care actions at the various levels of health care. SE2 states that there is greater engagement of the secretaries, because “they [...] are interested in using the CIR to improve the system as a whole” (SE2). Analysis of the meetings’ minutes shows several projects submitted by the municipalities concerning primary health care in their territory; however, observations show that, in these cases, managers of the other municipalities showed little interest and participation. It was observed in the minutes of CIR meetings that decisions still have little foundation on a regional diagnosis of health.

The same was also observed in the study of (Cecilio et al., 2007CECILIO, L. C. O. et al. O gestor municipal na atual etapa de implantação do SUS: características e desafios. Reciis: Revista Eletrônica de Comunicação, Informação & Inovação em Saúde, Rio de Janeiro, v. 1, n. 2, p. 200-207, 2007., p. 202) after qualitative assessment of the profile and professional career of municipal managers of a Regional Health Board of the State Secretariat of Health of São Paulo, reporting that municipal managers have become “important social actors in the SUS’ political and institutional context and, although in a limited way, provided opportunity for experimentation with new models and practices, aiming to overcome the diversity present in various cities and regions of the country.”

In this context, it is evident that the meeting between state and municipal managers is important for the construction of health policies at the regional and municipal levels, tackling the everyday problems that permeate the provision of health care. However, this potential is not fully developed to date, given the limited capacity for coordination of the managers involved. The CIR is a space with potential to develop the institutional capacity for regional territorial planning and coordination aimed at overcoming corporate interests and creating local governance founded on solidarity, democratization of decision, and intergovernmental cooperation (Viana, 2015VIANA, A. L. d’Á. et al. Tipologia das regiões de saúde: condicionantes estruturais para a regionalização no Brasil. Saúde & Sociedade, São Paulo, v. 24, n. 2, p. 413-422, 2015.).

Strengthening of the SUS

The municipal managers’ professional competence for coordinated planning of actions in health care, with effective support of the state management, enables studying and understanding the construction of the SUS (Cecilio et al., 2007CECILIO, L. C. O. et al. O gestor municipal na atual etapa de implantação do SUS: características e desafios. Reciis: Revista Eletrônica de Comunicação, Informação & Inovação em Saúde, Rio de Janeiro, v. 1, n. 2, p. 200-207, 2007.). Similarly, Decree No. 7,508 (Brasil, 2011BRASIL. Casa Civil. Subchefia para Assuntos Jurídicos. Decreto nº 7.508, de 28 de junho de 2011. Regulamenta a Lei nº 8.080, de 19 de setembro de 1990, para dispor sobre a organização do Sistema Único de Saúde (SUS), o planejamento da saúde, a assistência à saúde e a articulação interfederativa, e dá outras providências. Diário Oficial da União, Brasília, DF, 29 jun. 2011. Seção 1, p. 1-3.) highlights the importance of improving the health care networks in health regions in the construction of the assistance beyond the perspective of the organization of services (Shimizu, 2013SHIMIZU, H. E. Percepção dos gestores do Sistema Único de Saúde acerca dos desafios da formação das redes de atenção à saúde no Brasil. Physis: Revista de Saúde Coletiva, Rio de Janeiro, v. 23, n. 4, p. 1101-1122, 2013.).

When questioned about the potential of the CIR, the managers refer to points that converge to the strengthening of the SUS. The state public servants understand that the CIR meetings’ potential refers to the possibility of meetings between managers, resulting in the commitment of managements and in proposals for the health sector: “I see all decisions being directed so everything goes through the CIR, resulting in regional resolutions, it also makes this participation become something more permanent, systematic, and effective” (SE1).

The municipal managers also point out as powerful the possibility of organizing flows for the submission of projects. The presentation of these projects in meetings enables managers to get to know the projects that are developed by the neighboring municipalities: “we see the projects that other municipalities are doing” (GM1).

Municipal managers are fundamental actors in the evaluation and planning of services in their municipality and, at the time they become independent to recognize local health needs, they coordinate with state managers the allocation of resources for the communities (Santos; Andrade, 2009SANTOS, L.; ANDRADE, L. O. M. SUS: o espaço da gestão inovada e dos consensos interfederativos - aspectos jurídicos, administrativos e financeiros. 2. ed. Campinas: Saberes, 2009.). Thus, the provision of health care is expanded in all its dimensions, no longer being a service provided only in the locations of reference.

This space is also understood as a place of solidarity among the municipalities, according to GM4, when affirming that “whenever we needed something the CIR always supported us.” Another manager adds that “the CIR’s role is extremely important, I would even say indispensable for the smooth progress of projects at regional level” (GM5).

According to (Machado, 2009MACHADO, J. A. Pacto de gestão na saúde: até onde esperar uma “regionalização solidária e cooperativa”? Revista Brasileira de Ciências Sociais, São Paulo, v. 24, n. 71, p. 105-193, 2009.), it is necessary to overcome the sociopolitical stage in which the theme of solidarity is based only on documents, agendas, and joint resolutions of managers. Similarly, after analysis of results from this category, it is observed that the discussion proposed by the aforementioned author persists in the Regional Intermanagers Commissions, and has not been overcome.

Weaknesses of the management

Municipal managers have become important social actors in the political-institutional sphere, and understanding their role in the construction of the SUS involves two questions: their capacity of management considering the growing and complex responsibilities and the regional coordination between municipalities, with intermediation and support of the state manager, in its regional representation (Cecilio et al., 2007CECILIO, L. C. O. et al. O gestor municipal na atual etapa de implantação do SUS: características e desafios. Reciis: Revista Eletrônica de Comunicação, Informação & Inovação em Saúde, Rio de Janeiro, v. 1, n. 2, p. 200-207, 2007.).

The weakness of the management was highlighted in the discourse of the municipal and regional managers. Decree No. 7,508 (Brasil, 2011BRASIL. Casa Civil. Subchefia para Assuntos Jurídicos. Decreto nº 7.508, de 28 de junho de 2011. Regulamenta a Lei nº 8.080, de 19 de setembro de 1990, para dispor sobre a organização do Sistema Único de Saúde (SUS), o planejamento da saúde, a assistência à saúde e a articulação interfederativa, e dá outras providências. Diário Oficial da União, Brasília, DF, 29 jun. 2011. Seção 1, p. 1-3.) defines that the planning process should be ascendant and integrated, which presupposes active participation of the managers. However, it was observed that the positioning of most managers is of spectator and not of protagonist in the process, as corroborated by the statement: “strengthening this participation is also leaving a position of spectator” (GM1). This positioning may be related to the high turnover of municipal health managers, confirmed by the minutes of meetings, which complicates the appropriation of knowledge needed for decision making. In this condition, other actors show greater control over the agenda and greater power of argument, what influences the votes, according to observations.

Some municipal managers reported satisfaction due to being able to rely on the participation of regional public servants in the CIR, but positioning themselves as listeners and not as decision makers, as they deem themselves as having insufficient knowledge to do so: “already submits, he already walks and already gives his opinion, speaks up, not that the others don’t speak, but we ask and he knows it. He understands (referring to a regional public servant)” (GM4).

This behavior seems to be related to the lack of knowledge about the CIR and the role of management in integrated regional planning, as stated:

Concerning this issue, the Ministry of Health stated that “it should not be disregarded that the SUS is a unified system in a country of significant demographic and socioeconomic differences. Therefore, it is important to clarify the roles of federal entities in health regions and health networks, where the right to health becomes effective” (Brasil, 2011BRASIL. Casa Civil. Subchefia para Assuntos Jurídicos. Decreto nº 7.508, de 28 de junho de 2011. Regulamenta a Lei nº 8.080, de 19 de setembro de 1990, para dispor sobre a organização do Sistema Único de Saúde (SUS), o planejamento da saúde, a assistência à saúde e a articulação interfederativa, e dá outras providências. Diário Oficial da União, Brasília, DF, 29 jun. 2011. Seção 1, p. 1-3., p. 4).

Some respondents think that there is a lack of interest and commitment of regional public servants and municipal managers in the integrated regional planning process. This perception is observed in the discourse of GM2, who states that “sometimes some people arrive late, others come and leave early. […] We have here several areas that should participate and don’t. The audit, for example, that has the doctors, they have no involvement” (GM2).

This observation shows the lack of comprehension of municipal managers and regional public servants regarding the importance of this regional instance and its potential for the resolution of problems affecting the organization of health care in the region. Thus, there is little involvement in the processes of discussion and proposition of actions to address these problems. A network is actualized as long as there are political actors committed to its effectiveness. This requires a governance system in which coordination and cooperation between social and political actors and construction of new institutional arrangements may occur (Mendes, 2011MENDES, E. V. As redes de atenção à saúde. 2. ed. Brasília, DF: Organização Pan-Americana da Saúde, 2011. Disponível em: <Disponível em: https://goo.gl/jkDZqr >. Acesso em: 13 jan. 2014.
https://goo.gl/jkDZqr... ).

However, according to Medeiros there is a great gap between what is written and the possibility of establishing the norm in practice, because

The study of (Santos and Giovanella, 2014SANTOS, A. M.; GIOVANELLA, L. Governança regional: estratégias e disputas para gestão em saúde. Revista de Saúde Pública, São Paulo, v. 48, n. 4, p. 622-631, 2014.) in the CIR of a health region of the state of Bahia showed that the discussions were abbreviated to fit the short time for meetings, and that the managers often scattered, returning to the plenary for the moment of approval and homologation of projects, without the prospect of regional planning or evaluation.

The discourse of a regional public servant shows that participation in the CIR is not a priority for the regional management, not being recognized as space of effective decision-making for regional planning. It is inferred, through the reports, that as well as in the municipalities, the work processes of the CRS are fragmented and some public servants engage only in discussions related to their sphere of sectoral activities. What should be understood as a structuring activity is considered only as one more task: “My own participation, often I cannot participate because of the demand, we have a major lack of professionals, [...] it practically takes a professional who should be working in another activity to assume this role” (GM2).

In the state of São Paulo, it was found that the state sphere of power could also have difficulties to assume the effective coordination of regional planning. “In this sense, the historical construction of regional technical support that can enhance the committed solidary association of managers in building the regions has not been strengthened” (Mendes et al., 2015MENDES, Á. et al. O processo de construção da gestão regional da saúde no estado de São Paulo: subsídios para a análise. Saúde e Sociedade, São Paulo, v. 24, n. 2, p. 423-437, 2015., p. 436).

It is observed that in the region of this study most municipal managers have no training in the area of health. This fact is considered by a regional public servant as obstacle hindering quality management and effective participation in regional planning. The lack of qualified persons for the position in the municipality and the need to indicate political supporters end up having in the position individuals unable to work properly. These factors may be causing the high turnover in municipal and regional management, which was reported as a problem for planning, causing discontinuity in the process, hindering the understanding about the complexity of the health system and the strategies to respond to regional demands (Roese, 2012ROESE, A. Planejamento regional ascendente e regionalização: atores e estratégias da organização dos fluxos de utilização dos serviços de saúde. 2012. Tese (Doutorado em Enfermagem) - Escola de Enfermagem da Universidade Federal do Rio Grande do Sul, Porto Alegre, 2012.). This turnover may also be related to the tension produced in this arena of interests - often divergent -, causing the changes in the position, as reported by respondents: “there are secretariats that in one year and eight months already had two or three secretaries” (GM1); and “every time they come here, the guy comes without any knowledge and tries to learn health in a place that is intended to implement the ideas” (SE2).

Lack of knowledge in the area of health and management processes, in addition to lack of commitment in relation to regional health issues, are reflected in very fast decision-making, with no foundation or information, often misleading. As a result, the power falls in the hands of those who hold political and technical knowledge in this field. According to (Miranda, 2010MIRANDA, A. S. Processo decisório em Comissões Intergestores do Sistema Único de Saúde: governabilidade resiliente, integração sistêmica (auto)regulada. Política, Planejamento e Gestão em Saúde, Salvador, v. 1, n. 1, p. 117-139, 2010.), the decisions are not always product of understanding, but often the agreements are constrained by the imperatives of the “system,” of the time (deadlines), and of the established relations of power. Reading of the minutes shows the approval of most of the proposals presented in the CIR meetings, with few questions about the relevance of the same.

Similarly to Brazil, the Spanish National Health System (NHS) presents as weakness and instability the political appointment of the positions of responsibility in the health management, differently from the more advanced countries of Europe, such as the Norse ones, the United Kingdom, and Italy, whose management and managerial levels have non-partisan, technical, and stable character. Despite a growing culture of management, this does not come accompanied by the corresponding reflection and decisions on the good governance of the Spanish NHS. The Interterritorial Council is a scenario of partisan discrepancies and precariousness of the mechanisms of cohesion and coordination of the NHS (Freire, 2006FREIRE, J. M. El sistema nacional de salud español en perspectiva comparada europea: diferencias, similitudes, retos y opciones. Claridad - Sanidad, Madrid, v. 1, p. 31-45, jul.-set. 2006.).

(Leatt, Pink, and Guerriere, 2000LEATT, P.; PINK, G. H.; GUERRIERE, M. Towards a Canadian Model of integrated healthcare. Healthcare Papers, Toronto, v. 1, n. 2, p. 13-35, 2000. Disponível em: <Disponível em: http://www.longwoods.com/content/17216 >. Acesso em: 14 nov. 2015.
http://www.longwoods.com/content/17216... ), in discussing the Canadian model of health care, in which hospitals, clinics, and other health equipment are organized separately, reaffirm the need for countries to think their health systems in an integrated manner, networked, and also considering the diversity of scenarios of each region of the country. To this end, they suggest some strategies for change: fostering a view of singularity; focusing on primary health care; sharing information and exploring technology; creating parameters in virtual networks at the local level; developing practical methods of funding based on the needs; and implementing monitoring and evaluation mechanisms.

The managers’ doubts appear in the discourse of a participant of the study, in relation to the application of the health resources: “How should I spend, what could I do with such resource, this is my greatest difficulty today” (GM2). In addition to ignorance, the manager shows insecurity, possibly caused by the earmarking of the resources to certain actions, with little flexibility for adaptation to the needs of the municipality. The difficulty of the CIR to monitor the application of approved resources was also observed, being evident that often they have no information about the allocation of resources in the region, and also no information if it was properly applied.

The inefficiency to resolve regional problems is reflected in the items in the agenda of the CIR, with recurring discussions, without practical implementation of the plans proposed. The interfederational pact, in this context, is not actualized, as the problems impact with different intensity the three spheres of the government. The municipality, with the demands of everyday situations, is more affected by the urgency in responding to problems: “A difficulty is pointed out and there is a whole process of a resolution coming from the CIR, reaching the departments of the state government, and the response takes a long time to happen. […] We have a great difficulty of access to some specialties” (GM5). “Because of difficulties of definition, the subjects return and affect the very collective negatively, and then sometimes we cannot pose other topics for discussion” (GE1).

The lack of resolution and the insufficient response from the state were also found in a study conducted in Brasília, with health managers who expressed concerns about the lack of definition of roles in relation to which sphere of the government will assume the responsibility of ensuring access to services of higher technological density. They also stressed the fear that there will be difficulty in ensuring that some states contribute with adequate funding to the health regions (Shimizu, 2013SHIMIZU, H. E. Percepção dos gestores do Sistema Único de Saúde acerca dos desafios da formação das redes de atenção à saúde no Brasil. Physis: Revista de Saúde Coletiva, Rio de Janeiro, v. 23, n. 4, p. 1101-1122, 2013.).

The weakness of the management was also evidenced by the difficulty in facing and negotiating with private health care service providers in relation to the interests of the region: “The even commented with us, but when it involves the service provider they end up not talking about it” (SE3). The actions are driven by specific problems, with no observable movements of effective organization of the health care networks.

In a study conducted in the same region, it was observed that the municipal managers are conformed and feel unable to face the decisions taken by private service providers, which denotes their difficulty of empowerment in decision-making processes (Medeiros, 2013MEDEIROS, C. R. G. Redes de atenção em saúde: o dilema dos pequenos municípios. 2013. Tese (Doutorado em Enfermagem) - Escola de Enfermagem da Universidade Federal do Rio Grande do Sul, Porto Alegre, 2013.). There is, in some ways, a dependency relationship of the manager in relation to the service provider, with support in the need to ensure that the everyday demands are met, especially with regard to medium and high complexity. Another study, conducted in a health region of the state of Bahia, also found that the municipal managers could not regulate properly the private health sector contracted. It found that the CIR had no mechanisms to prevent abuses of private service providers, such as increase of amounts charged to the SUS and direct charges to users (Santos; Giovanella, 2014SANTOS, A. M.; GIOVANELLA, L. Governança regional: estratégias e disputas para gestão em saúde. Revista de Saúde Pública, São Paulo, v. 48, n. 4, p. 622-631, 2014.).

Decentralization without regional integration and “weaknesses in the power of the state in the provision of services of higher complexity, with the presence of large gaps of health care in huge areas of the Brazilian territory, enabled the growth of the private service provision” (Viana, 2015VIANA, A. L. d’Á. et al. Tipologia das regiões de saúde: condicionantes estruturais para a regionalização no Brasil. Saúde & Sociedade, São Paulo, v. 24, n. 2, p. 413-422, 2015., p. 420) and consequent dependence thereof.

What has guided the meetings of the CIR

Two points were observed as guiding the agenda of the CIR: difficulties with the medium and high complexity and the approval of financial incentives provided by the State and Federal Union. When asked about which topics were more present in the agenda, six of the eight participants highlighted the discussions involving the care in medium and high complexity. It is observed that this fact is motivated mainly by the deficiency of references for specialties, especially trauma, according to this municipal manager’s straightforward remark: “When I don’t have a reference, what do I do? We’re tired here of having a hot potato in our hands, so who am I going to ask for help?” (GM1).

The regional management public servants support this perception:

According to (Silva, 2011SILVA, S. F. Implantando o pacto pela saúde e aperfeiçoando as redes de atenção do SUS. In: SILVA, S. F. et al. Redes de atenção à saúde no SUS: o pacto pela saúde e redes regionalizadas de ações e serviços de saúde. 2. ed. Campinas: Saberes, 2011. p. 12-20., p. 12) society “demands from managers the access to services and it is not uncommon that they consider that the causes of suppressed demand are due to inefficiency of the management, because of insufficient organization of existing services and inadequate regulation for their use.” This claim of the users directs the manager’s concern to serve them. In this context, issues related to primary health care in the municipalities are not prioritized, especially in the assessment of state public servants: “We try to show them a different perspective, convince them that basic care is more important, because it reduces the pressure at the other end, but it is difficult because of the emergency that they have to solve specific problems” (SE2).

The difficulty in ensuring care in medium and high complexity was also reported by the study of (Shimizu, 2013SHIMIZU, H. E. Percepção dos gestores do Sistema Único de Saúde acerca dos desafios da formação das redes de atenção à saúde no Brasil. Physis: Revista de Saúde Coletiva, Rio de Janeiro, v. 23, n. 4, p. 1101-1122, 2013.), which found that the services are distributed fairly unevenly in the country, with the aggravating factor that they did not manage to establish mechanisms of co-management between the public system and the services contracted, causing the regional networks to have little integration. The study of (Santos and Giovanella, 2014SANTOS, A. M.; GIOVANELLA, L. Governança regional: estratégias e disputas para gestão em saúde. Revista de Saúde Pública, São Paulo, v. 48, n. 4, p. 622-631, 2014.) found that regional strategies for strengthening the public network were focused on demanding the expansion of specialized and hospital service, without coordinated actions for the strengthening and greater resolution of Primary Health Care (PHC).

In the report of a municipal manager, however, it is observed the understanding that this space could include debates on other demands faced in everyday work: “In fact I believe topics related to our day to day of the secretariat, to exchange ideas, this hasn’t been done” (GM1). The complaint expresses the need for support for the diagnosis of reality and the planning of actions and services that address the local problems.

It was found that items related to the financial incentives provided by the State Secretariat of Health and by the Ministry of Health are a significant part of the agendas of CIR meetings, as they must be approved by this collective, in the logic of a regional organization of health care service. However, the interest of municipal managers is often limited to access to these incentives, with little focus on other issues.

Decree No. 7,508 (Brasil, 2011BRASIL. Casa Civil. Subchefia para Assuntos Jurídicos. Decreto nº 7.508, de 28 de junho de 2011. Regulamenta a Lei nº 8.080, de 19 de setembro de 1990, para dispor sobre a organização do Sistema Único de Saúde (SUS), o planejamento da saúde, a assistência à saúde e a articulação interfederativa, e dá outras providências. Diário Oficial da União, Brasília, DF, 29 jun. 2011. Seção 1, p. 1-3.) states that health planning is compulsory for public entities and will induce policies for the private sector. Nevertheless, in the assessment of state public servants, the planning is not properly taken into account in the discussions of the CIR: “How is the system organized, how do I plan the service there at the clinic. How do I improve the oral health issue? The planning is hardly mentioned in the CIR” (SE2).

Although Decree No. 7,508 (Brasil, 2011BRASIL. Casa Civil. Subchefia para Assuntos Jurídicos. Decreto nº 7.508, de 28 de junho de 2011. Regulamenta a Lei nº 8.080, de 19 de setembro de 1990, para dispor sobre a organização do Sistema Único de Saúde (SUS), o planejamento da saúde, a assistência à saúde e a articulação interfederativa, e dá outras providências. Diário Oficial da União, Brasília, DF, 29 jun. 2011. Seção 1, p. 1-3., p. 8), determines that “the health planning process will be ascendant and integrated, from the local level to the federal level,” the category’s analysis described below showed the lack of regional integration and a strong individualism among managers in decision-making.

Individualism in observing the process

Definition of the CIR’s role in the construction of a regional planning system depends, fundamentally, on the engagement of actors participating in the scenario. Thus, the sum of efforts may signify a productive, transforming process. However, what we see is that this harmony of objectives is not routine in the CIR, as pointed out by a municipal manager, saying that “perhaps the greatest difficulty is that municipalities join to fight against the entities, let’s say, against a hospital, it is pointless to go there to discuss a contract (alone)” (GM2). The statement of this respondent is corroborated by other municipal manager, who questions the low participation of a number of managers, who participate in the event that there is some item of local interest in the agenda. In this sense, (Silva and Gomes, 2013SILVA, E. C.; GOMES, M. H. A. Impasses no processo de regionalização do SUS: tramas locais. Saúde e Sociedade, São Paulo, v. 22, n. 4, p. 1106-1116, 2013.), in evaluating the process in the ABC region in São Paulo, stress the political division between the representations within the CIR as the reason of difficulty for the collective interest, thus stimulating an individualistic perspective.

A municipal manager, in analyzing this aspect, states that “maybe there is something missing like union” (GM2). In the same vein, a state public servant adds: “the difficulty of leaving this position to see what will contribute to improve the health issues, voting in favor or against a particular health project, support a particular extension of service” (SE1).

According to (Silva, 2011SILVA, S. F. Implantando o pacto pela saúde e aperfeiçoando as redes de atenção do SUS. In: SILVA, S. F. et al. Redes de atenção à saúde no SUS: o pacto pela saúde e redes regionalizadas de ações e serviços de saúde. 2. ed. Campinas: Saberes, 2011. p. 12-20., p. 17), this determination to defend local projects to the detriment of the health network leads to difficulties in the construction of local solutions, and municipal managers should assess “the distribution of health care services in territories of municipalities and of the region and, considering the usually deficient provision, distribute them as fairly as possible, in order to guarantee access, bond, and continuity of care for the most needy population.”

Based on the interviews, it can be inferred that the individual position predominates over the collective interest, as topics are treated according to each participant’s demand, which is corroborated by the study of (Silva, 2011SILVA, S. F. Implantando o pacto pela saúde e aperfeiçoando as redes de atenção do SUS. In: SILVA, S. F. et al. Redes de atenção à saúde no SUS: o pacto pela saúde e redes regionalizadas de ações e serviços de saúde. 2. ed. Campinas: Saberes, 2011. p. 12-20.). A municipal manager points out that the meetings are even emptied as the most urgent items are won. Such behavior weakens the political arena, wasting the effective possibility of building mechanisms to improve the integrated regional planning. “The weaknesses of the political-administrative construction of Regional Management Committees make them more vulnerable to private interests at the expense of collective interests” (Mendes et al., 2015MENDES, Á. et al. O processo de construção da gestão regional da saúde no estado de São Paulo: subsídios para a análise. Saúde e Sociedade, São Paulo, v. 24, n. 2, p. 423-437, 2015., p. 436).

A study conducted in São Paulo showed that it is important to strengthen the regional management’s role in the state, as its proactivity in the organization and establishment of spaces for negotiation and assessment of the agreement processes had positive impact on the referencing between municipalities (Venancio et al., 2011VENANCIO, S. I. et al. Referenciamento regional em saúde: estudo comparado de cinco casos no estado de São Paulo, Brasil. Ciência & Saúde Coletiva, Rio de Janeiro, v. 16, n. 9, p. 3951-3964, 2011.).

Final remarks

The integrated regional planning process has advanced in the sense of constituting a space of mutual support between the municipal and state management. However, the individualistic behavior persists, with little advance in the proposal of integrated and solidary action, which would have the potential to strengthen and improve the health regions.

Health management still reproduces a logic that is out of context and based on demands and complaints considered in isolation, aimed at treating the current “symptom” of the problem. This form of conducting the management has contributed to the lack of planning and of proposition of strategies that ensure resources that meet the regional demands for the different levels of complexity of the health care network.

Decree 7,508/2011 establishes, as duty of the CIR, to guide and organize the flows of health care actions and services; nevertheless, for this to be effective it is essential to determine the needs of the region, defining the demands and provisions of services. However, it was not observed that the managers had knowledge about the regional reality, predominating decisions with more political than technical basis. Another important duty, according to the Decree, is monitoring the access to health care actions and services. The CIR showed insufficient technical conditions to monitor the services for which financial incentives and resources were approved, regarding both issues of access and quality of care. The problems found were specific and not formally reported to the State Secretariat of Health. This fact contributes to weaken the capacity of control and of negotiation with private service providers.

It is believed that the consolidation and strengthening of the CIR are fundamental to promote regional governance and effectiveness of the health care networks. However, it requires the qualification and effective participation of municipal health managers. In this perspective, participation of state public servants as coordinators of this process is also essential, considering the turnover of the municipal management. To this end, the state management needs increased understanding of the relevance of assuming and exercising this role, with technical preparation, because this study showed that regional planning has not been a priority and that public servants are not fully prepared to participate in this process.

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