Abstract

This article discusses the challenges faced by the state managers of the Brazilian National Health System (SUS) in the context of the COVID-19 pandemic and the consequences for their personal lives. From interviews with state managers, it became evident that the pandemic implied the replanning of health actions and services, the structuring of new hospital services and beds, the use of telemedicine, and the hiring and training of professionals. It also exposed the lack of integrated policies and national coordination, which led to states adopting different strategies. These factors, as well as the politicization of the pandemic, the denial of the disease, and the attempt of the federal government to impose ineffective treatments for COVID-19 were considered among the greatest difficulties experienced by managers. Managing the SUS became a risky exercise, with deleterious repercussions not only for themselves and their management, but also for their families and friends. If, on the one hand, the strenuous context affected the managers’ physical and mental health, who began dealing with overweight, anxiety, and anguish, on the other hand, it was a source of motivation for catalyzing solidarity, empathy, and sharing among political actors.

Keywords:
Health Manager; Brazilian National Health System; COVID-19; Health Management; Occupational Health

Introduction

Management can be understood as a practice developed in the daily exercise of work, which associates science, art, and skill. The practice of management occurs on three levels, from the conceptual to the concrete: the level of information, the level of people, and the level of action. They involve a combination of thinking, critical analysis, conflict negotiation, decisions, actions, and leadership to respond to the demands and needs of organizational systems (Mintzberg, 2010MINTZBERG, H. Managing: desvendando o dia a dia da gestão. Porto Alegre: Bookman, 2010.).

The classic functions of a manager - planning, coordination, organization, and control - emphasize the objective, rational, systematic, and decisive dimension of management. However, in addition to rationality, in the practice of management it is also important to consider the subjective dimension, represented by unpredictability, including in human relationships. Therefore, the managerial skills involved in the decision-making process are not restricted to the formal aspects of scheduling, budgeting, and controlling. It is up to managers to deal with administrative behavior, which encompasses the social and political context, but also aspects related to individual and collective relationships, such as motivation, working conditions, conflicts, and the individuals’ commitment to cooperative action (Motta, 2002MOTTA, P. R. Gestão contemporânea: a ciência e a arte de ser dirigente. Rio de Janeiro: Record, 2002.; Mintzberg, 2010MINTZBERG, H. Managing: desvendando o dia a dia da gestão. Porto Alegre: Bookman, 2010.).

The challenge posed by the implementation of the Brazilian National Health System (SUS) requires the ever-increasing use of tools and technologies that facilitate the identification of the main health problems and enable the evaluation of efficient and effective interventions. The complexity of this system presents itself as a challenge for any manager, because, more than an administrator, the SUS manager is considered the health authority in each sphere of government, whose action must be guided by the principles of the Brazilian health reform.

Three dimensions that are inseparable from the performance of health managers in the SUS - political, technical, and administrative - can be distinguished, which help to understand the complexity and dilemmas that arise from performing this public function (Souza; Bahia, 2014SOUZA, L. E. P. F.; BAHIA, L. Componentes de um sistema de serviços de saúde. In: PAIM, J. S.; ALMEIDA-FILHO, N. Saúde coletiva: teoria e prática. Rio de Janeiro: MedBook, 2014. p. 49-68.). On the one hand, the political dimension is expressed by the fact that the occupant of the position of minister or secretary of health is appointed by the head of the Executive Branch elected in each sphere of government. This situates the health manager as a member of a team that is committed to a particular government project. On the other hand, as a health authority, the health manager has the responsibility to conduct health policies according to the constitutional and legal determinations of the SUS, whose model of State policy does not finish after the end of a government’s mandate. In this aspect, there is an interaction between the government project and the State policy for health, which expresses tensions that influence the continuity or discontinuity of public policies (Souza, 2009SOUZA. L. E. P. F. O SUS necessário e o SUS possível: estratégias de gestão: uma reflexão a partir de uma experiência concreta. Ciência & Saúde Coletiva, Rio de Janeiro, v. 14, n. 3, p. 911-918, 2009. DOI: 10.1590/S1413-81232009000300027
https://doi.org/10.1590/S1413-8123200900... ; Machado et al., 2011MACHADO, C. V. et al. Princípios organizativos e instâncias de gestão do SUS. In. GONDIM, R. et al. (Org). Qualificação dos gestores do SUS. Rio de Janeiro: Fiocruz, 2011. p. 47-72. ; Souza; Bahia, 2014SOUZA, L. E. P. F.; BAHIA, L. Componentes de um sistema de serviços de saúde. In: PAIM, J. S.; ALMEIDA-FILHO, N. Saúde coletiva: teoria e prática. Rio de Janeiro: MedBook, 2014. p. 49-68.).

From this perspective, the political performance of the SUS manager is expressed in their relationship with various groups and social actors, in the different spaces of negotiation and decision-making, whether formal or informal. This requires devoting time and energy to establishing relationships and interactions with other government departments, other branches of government, and civil society. The challenge of this dimension is to make political-institutional and socio-political relations useful to the project of consolidating the SUS and the right to health (Souza, 2009SOUZA. L. E. P. F. O SUS necessário e o SUS possível: estratégias de gestão: uma reflexão a partir de uma experiência concreta. Ciência & Saúde Coletiva, Rio de Janeiro, v. 14, n. 3, p. 911-918, 2009. DOI: 10.1590/S1413-81232009000300027
https://doi.org/10.1590/S1413-8123200900... ; Machado et al., 2011MACHADO, C. V. et al. Princípios organizativos e instâncias de gestão do SUS. In. GONDIM, R. et al. (Org). Qualificação dos gestores do SUS. Rio de Janeiro: Fiocruz, 2011. p. 47-72. ).

The technical dimension is related to the objective of conducting the health system in accordance with the technical precepts of public/collective health, in a manner consistent with the principles of the public health system and public management (Souza, 2009SOUZA. L. E. P. F. O SUS necessário e o SUS possível: estratégias de gestão: uma reflexão a partir de uma experiência concreta. Ciência & Saúde Coletiva, Rio de Janeiro, v. 14, n. 3, p. 911-918, 2009. DOI: 10.1590/S1413-81232009000300027
https://doi.org/10.1590/S1413-8123200900... ). This is the dimension that gives specificity to health management, encompassing the actions of identifying and prioritizing health problems and proposing and implementing solutions. From this perspective, knowledge, skills, and experiences in the field of public management and health are necessary for managers (Machado et al., 2011MACHADO, C. V. et al. Princípios organizativos e instâncias de gestão do SUS. In. GONDIM, R. et al. (Org). Qualificação dos gestores do SUS. Rio de Janeiro: Fiocruz, 2011. p. 47-72. ). The administrative dimension refers to the objective of ensuring the coordination of the health system. Specifically, it brings together actions to mobilize skills and make efficient use of human, financial, material, and technological resources (Souza, 2009SOUZA. L. E. P. F. O SUS necessário e o SUS possível: estratégias de gestão: uma reflexão a partir de uma experiência concreta. Ciência & Saúde Coletiva, Rio de Janeiro, v. 14, n. 3, p. 911-918, 2009. DOI: 10.1590/S1413-81232009000300027
https://doi.org/10.1590/S1413-8123200900... ; Souza; Bahia, 2014SOUZA, L. E. P. F.; BAHIA, L. Componentes de um sistema de serviços de saúde. In: PAIM, J. S.; ALMEIDA-FILHO, N. Saúde coletiva: teoria e prática. Rio de Janeiro: MedBook, 2014. p. 49-68.).

In view of the above, the management of the Brazilian health system is a major challenge for those who occupy management positions and functions in the governmental structure. In his article entitled “O desafio de ser gestor da saúde no Brasil” [The challenge of being a health manager in Brazil], Raggio (2015RAGGIO, A. O desafio de ser gestor da saúde no Brasil. Consensus, [s. l.], ano 5, n. 14, p. 34-37, 2015. )¹1Armando Raggio served as municipal health secretary of Curitiba/PR, São José dos Pinhais/PR, and Sorocaba/SP; he was state health secretary of Paraná and president of the National Council of Municipal Health Secretariats (CONASEMS) and the National Council of Health Secretaries (CONASS). states that being a manager is not the same as being called a manager. He makes the following recommendation to those in this position:

In the context of the COVID-19 pandemic, the role of the manager became even more crucial and difficult. The speed with which the disease spread, its potential for transmission and contamination, the lack of scientific evidence on the virus, and the absence of effective pharmacological approaches and vaccines added complexity and uncertainty to the strategies for dealing with it, requiring managers to make agile decisions (Mendes, 2020MENDES, E. V. O lado oculto de uma pandemia: a terceira onda da covid-19 ou o paciente invisível. Brasília: Conselho Nacional de Secretários de Saúde , 2020.).

Several studies have been published on the management in SUS. However, little is said about the SUS manager, whether as a political actor, health worker, or even a civilian, who has a life trajectory, aspirations, difficulties, and challenges (Castro et al., 2022CASTRO, J. L. et al. Evidências e lacunas na produção científica sobre os gestores do SUS: scoping review. New Trends in Qualitative Research, Aveiro, v. 13, e699, 2022. DOI: 10.36367/ntqr.13.2022.e699
https://doi.org/10.36367/ntqr.13.2022.e6... ), and even less about their difficulties in the context of the pandemic. This article aims to discuss the challenges of state management of the COVID-19 pandemic and its repercussions for the life of the manager.

Methodology

The research that gave rise to this article is characterized by being exploratory and qualitative. For its development, different data collection techniques were employed: bibliographic research, which sought to map and analyze the scientific production on SUS managers; consultation of the institutional websites of the state health departments, to elaborate a descriptive diagnosis of the organization and activities of these structures; documentary research, the object of which was the state contingency plans prepared to deal with the COVID-19 pandemic; and semi-structured interviews with SUS managers. These techniques resulted in an extensive set of data that has not yet been published, some of which are presented in this article, focusing in particular on the results found in the interviews with key informants.

Seven state health secretaries from the Northeast, South, and Southeast regions, one former secretary, and a representative of the National Council of Health Secretaries (CONASS) were interviewed. The inclusion of the latter in the research is justified by their position in the SUS management scenario, which allows them to follow the diversified trajectories of state health managers.

The interviews were conducted remotely, via the Zoom platform, from April 2021 to March 2022. They were previously scheduled according to the managers’ availability and lasted an average of 60 minutes. To guide the researcher, a script was used containing guiding questions related to the respondent’s academic-professional trajectory, their perception of being a health manager and the implications of the position for their life, and regarding the pandemic and the role of the health manager in this context.

All interviews were recorded on audio and transcribed in full. Then, the transcripts were thoroughly read, in order to enable their coding, categorization, and interpretation. This process was carried out using content analysis, as proposed by Bardin (2011BARDIN, L. Análise de conteúdo. São Paulo: Edições 70, 2011.), which consists of a set of techniques for analyzing and processing communications via systematic procedures for describing messages. This article puts into perspective the discussions related to two categories that emerged from the analysis: state management of the COVID-19 pandemic and the repercussions of pandemic management for the manager.

The research complied with all ethical precepts related to research with human beings, and the project was submitted, evaluated, and approved by the Research Ethics Committee of the University Hospital of the Federal University of Rio Grande do Norte, Opinion 4.880.629. To ensure anonymity, in this article, the participants were numbered in sequence (E1, E2, ...), according to the order in which the interviews were conducted.

The state’s management of the COVID-19 pandemic

The State Department of Health (SES) is a direct public administration body of the state government, responsible for developing state health policy. It thus became the state manager of the SUS, as defined by the Organic Health Law of September 19, 1990 (Brasil, 1990BRASIL. Lei nº 8.080, de 19 de setembro de 1990. Dispõe sobre as condições para a promoção, proteção e recuperação da saúde, a organização e o funcionamento dos serviços correspondentes e dá outras providências. Diário Oficial da União, Brasília, DF, 20 set 1990. Disponível em: Disponível em: https://www.planalto.gov.br/ccivil_03/leis/l8080.htm . Acesso em: 10 out 2023.
https://www.planalto.gov.br/ccivil_03/le... ). The SES are present in all Brazilian states and the Federal District, and their primary function is to develop state health policy. Despite the differences, most SES carry out comprehensive management, that is, a management that is not restricted to managing their own service network, the service providers under their management, and some assistance programs. It also incorporates the functions of regulation, formulation, and evaluation of health policies, negotiation, and coordination of state health policy (CONASS, 2023CONASS - Conselho Nacional de Secretários de Saúde. Guia de apoio à gestão estadual do SUS. Brasília, DF: Conass , 2022. Disponível em: Disponível em: https://www.conass.org.br/guiainformacao/ >. Acesso em: 12 fev 2023.
https://www.conass.org.br/guiainformacao... ).

To this set of functions is added the management and execution of special services and actions, such as public health laboratories, blood centers, transplant services, and pharmaceutical assistance, which are common to all departments. It is therefore assumed that the SES work to strengthen the system and, in line with its principles and guidelines, ensure comprehensive health care for the population, by promotion, prevention, assistance, and rehabilitation actions (CONASS, 2023CONASS - Conselho Nacional de Secretários de Saúde. Guia de apoio à gestão estadual do SUS. Brasília, DF: Conass , 2022. Disponível em: Disponível em: https://www.conass.org.br/guiainformacao/ >. Acesso em: 12 fev 2023.
https://www.conass.org.br/guiainformacao... ).

The management of such a complex institution, during what was one of the most serious health crises of the century, required significant efforts from the state management and all the care and management workers.

SARS-CoV-2, which causes COVID-19, was reported in December 2019 in Wuhan, a Chinese province. Due to the high degree of transmissibility of the virus, the World Health Organization (WHO) declared a public health emergency of international concern on January 30, 2020, in accordance with international health regulations. The pandemic was declared on March 11 of the same year, alerting countries to the need to create strategies to control the transmission of the virus and organize health systems. At that time, more than 115,000 cases and 4,000 deaths had already been reported in 114 countries (PAHO, 2020).

In Brazil, a public health emergency of national importance was declared on February 3, 2020, accompanied by the activation of the Public Health Emergency Operations Center for the new Coronavirus (Brazil, 2020BRASIL. Ministério da Saúde. Portaria nº 188, de 3 de fevereiro de 2020. Declara Emergência em Saúde Pública de importância Nacional (ESPIN) em decorrência da infecção humana pelo novo Coronavírus (2019-nCoV). Diário Oficial da União , Brasília, DF, 4 fev 2020. Disponível em: < Disponível em: https://www.in.gov.br/en/web/dou/-/portaria-n-188-de-3-de-fevereiro-de-2020-241408388 >. Acesso em: 10 out 2023.
https://www.in.gov.br/en/web/dou/-/porta... ) and the publication of the first version of the National Contingency Plan for Human Infection by the New Coronavirus (Brazil, 2021BRASIL. Ministério da Saúde. Centro de Operações de Emergências em Saúde Pública. Plano de Contingência Nacional para Infecção Humana pelo novo Coronavírus COVID-19. Brasília, DF: Ministério da Saúde, 2021. Disponível em: <Disponível em: https://www.gov.br/saude/pt-br/coronavirus/publicacoes-tecnicas/guias-e-planos/livreto-plano-de-contingencia-espin-coe-26-novembro-2020 >. Acesso em: 24 mar 2023.
https://www.gov.br/saude/pt-br/coronavir... ).

The state governments and the Federal District, via their health departments, also announced their contingency plans. Understood as an instrument of government planning, these plans aimed to contain the advance of the disease and strengthen the surveillance system and actions to prevent and control the pandemic (Vieira et al., 2023VIEIRA, S. L. et al. Ações de educação permanente em saúde em tempos de pandemia: prioridades nos planos estaduais e nacional de contingência. Ciência & Saúde Coletiva , Rio de Janeiro, v. 28, n. 5, p. 1377-1386, 2023. DOI: 10.1590/1413-81232023285.11252022
https://doi.org/10.1590/1413-81232023285... ). Thus, these documents announced immediate strategic decisions, established responsibilities and priorities, and guided the investments of resources needed to respond to the health emergency.

Given the alarming context of virus transmission, dealing with the pandemic became the priority activity of health departments and services, to the detriment of all others. As a result, the SES announced several control and prevention measures to be implemented within their service networks. Health actions were redesigned, new services were structured, hospital beds were opened, and the use of telemedicine was expanded, as shown in the excerpts below:

It can be seen that crisis management did not replace the reasoning of planning; on the contrary, planning was the basis for organizing coping actions (Caleman et al., 2021CALEMAN, G. et al. O planejamento estratégico situacional em tempos de crise. In: SANTOS, A. O.; LOPES, L. T. (Org.). Planejamento e saúde. Brasília, DF: Conselho Nacional de Secretários de Saúde, 2021. p. 40-50.). The pandemic found in the managers of the SES a posture of flexibility; a constantly revised attitude that took into account the situations and circumstances, so that the system of actions was based on knowledge of the reality of each moment, as proposed by situational strategic planning (Matus, 1978MATUS, C. Estrategia y plan. México: Siglo XXI, 1978.). Thus, given the context of crisis and uncertainty, which was marked initially by gaps in knowledge, state managers had the important task of designing solutions to deal with the pandemic, taking into account the peculiarities of their territory and its sociopolitical context. In practice, the managers showed what a living plan is, one that can be modified in real time.

With this in mind, the state contingency plans were designed with the purpose of instrumentalizing the management of the state public health network and services with a view to reducing the complications and damage caused by COVID-19. At first, the plans were restricted, in practice, to indicating actions to monitor new cases and expand the specialized network, especially the supply of beds, which was effectively carried out by the management.

In the fight against the pandemic in Brazil, efforts were focused on hospital services, with investments aimed especially at opening field hospitals - many of which were not ready in a timely manner - and intensive care unit beds. Primary care, in turn, was underutilized, which may have been regarded a strategic error when considering its territorial capillarity and the power of multiprofessional teamwork in the Family Health Strategy (Medina et al., 2020MEDINA, M. G. et al. Atenção primária à saúde em tempos de COVID-19: o que fazer? Cadernos de Saúde Pública, Rio de Janeiro, v. 36, n. 8, p. e00149720, 2020. DOI: 10.1590/0102-311X00149720
https://doi.org/10.1590/0102-311X0014972... ; Massuda et al., 2021MASSUDA, A. et al. A resiliência do Sistema Único de Saúde frente à COVID-19. Cadernos EBAPE.BR, Rio de Janeiro v. 19, p. 7350744, nov. 2021. Edição especial.). This perspective was corroborated by the lack of mentions of primary care by the interviewees.

Despite this, as the pandemic progressed, scientific evidence was produced and knowledge about the impacts of COVID-19 expanded, contingency plans began to incorporate new actions based on the needs produced by the health crisis, such as professional training and support for education, monitoring, and remote healthcare. On the other hand, aspects of work management were very little addressed by the plans, such as the scaling of workers to deal with the pandemic, reorganization of work processes, adaptation of working hours, mental health, and forms of hiring. In contrast, in order to operate the demands imposed by the pandemic, issues related to the health workforce had to be addressed.

It should be emphasized that the pandemic was not the cause of precariousness in the health sector, but a factor that aggravated the historical, chronic, and precarious working and health conditions of workers in the sector, marked by work overload, lack of material resources for care, shortage of professionals, professional devaluation, and low pay (Aith et al., 2020AITH, F. et al. Is COVID-19 a turning point for the health workforce?. Revista Panamericana de Salud Publica, Washington, DC, v. 44, e102, 2020. DOI: 10.26633/RPSP.2020.102
https://doi.org/10.26633/RPSP.2020.102... ; Barreto et al., 2021BARRETO, M. S. et al. Vivências de enfermeiros e médicos de unidades de pronto atendimento no enfrentamento da covid-19. Revista Baiana de Enfermagem, Salvador, v. 35, e43433, 2021. DOI: 10.18471/rbe.v35.43433
https://doi.org/10.18471/rbe.v35.43433... ; Castro; Bridges, 2021CASTRO, J. L.; PONTES, H. J. C. A importância dos trabalhadores da saúde no contexto covid-19. In: SANTOS, A. O.; LOPES, L. T. Profissionais de saúde e cuidados primários. Brasília, DF: Conass, 2021. p. 40-52.).

The new coronavirus also exposed the absence of integrated policies and national coordination on the part of the Brazilian Ministry of Health, which led to the adoption of different strategies by each state. These factors, as well as the politicization of the pandemic, the denial of the disease, and the attempt to impose ineffective treatments for COVID-19 by representatives of the federal government, were considered the greatest difficulties experienced by those who were in charge of state actions aimed at tackling the pandemic.

It is worth remembering that, in 16 months of the pandemic, between the requests for exonerations and the dismissals, there were 15 changes of state health secretaries. In the Ministry of Health, there were four ministers in the period. This movement caused a rupture in the administrative processes and in the articulations of political decisions already taken, as one of the interviewees informs:

Add to this the escalation of the process of dismantling health funding and the lack of greater commitment to allocating resources to tackle the pandemic. In this regard, Mendes, Carnut, and Melo (2023MENDES, A.; CARNUT, L.; MELO, M. Continuum de desmontes da Saúde Pública na crise do covid-19: o neofascismo de Bolsonaro. Saúde e Sociedade, São Paulo, v. 32, 2023. DOI: 10.1590/S0104-12902022210307pt
https://doi.org/10.1590/S0104-1290202221... ) argue that the actions, or lack thereof, consisted of an orientation in tune with scientific denialism and the practices of neo-fascists who despised the lives of the most vulnerable.

The repercussions of managing the pandemic for the manager

Seligmann-Silva (2011SELIGMANN-SILVA, E. Trabalho e Desgaste Mental: o direito de ser dono de si mesmo. São Paulo: Cortez, 2011., p. 34) states that the social process involves individuals and interacts in their psychosomatic complexity, since “political and social forces can favor or weaken the health of human beings according to the situations they experience in macrosocial contexts and specific life and work situations.” From this perspective, it is fair to assume, based on the analysis of the managers’ statements, that the serious, controversial, and delicate sociopolitical context made the management of COVID-19 more complex and tense, having an impact on the personal lives of the managers responsible for running the state’s SUS. One of the managers alluded to this process:

Another informant described management as intense and very absorbing, in addition to:

This strenuous context, with little time for breaks, produced consequences such as stress, depression, physical problems, obesity, worsening of some existing problems, and a feeling of permanent anguish as a result of the limitations and impossibilities faced on a daily basis.

Routinely, the workload assigned to SUS management goes far beyond the eight hours a day usually established for workers in Brazil. During the COVID-19 pandemic, this workload was exponentially increased and expanded to weekends. According to Sousa et al. (2020SOUSA, K. H. J. F. et al. Factors related to the risk of illness of nursing staff at work in a psychiatric institution. Revista Latino-Americana de Enfermagem, Ribeirão Preto, v. 28, e3235, 2020. DOI: 10.1590/1518-8345.3454.3235
https://doi.org/10.1590/1518-8345.3454.3... ), in a general context, increased working hours are associated with a greater predisposition to occupational illness. The result of this work overload is insomnia, anxiety, nervousness, depression, and other mental health problems, particularly burnout syndrome (Soares et al., 2022SOARES, J. P. et al. Fatores associados ao burnout em profissionais de saúde durante a pandemia de Covid-19: revisão integrativa. Saúde em Debate, Rio de Janeiro, v. 46, p. 385-398, 2022. Edição especial. DOI: 10.1590/0103-11042022E126
https://doi.org/10.1590/0103-11042022E12... ). The impact of the pandemic on state health secretaries was no different.

Another important element to consider, in the tense context in which the COVID-19 pandemic was managed, was the aggressive positioning on social networks, in which defamation, insult, and the incitement to hatred, directed at the management of the SUS, were common. In the pandemic context, the repercussions of the attacks on social networks spread to family and friends, causing widespread suffering, as one of the interviewees mentioned:

Regarding the current context, marked by the strong presence and influence of social networks, Han (2022HAN, B-C. Não coisas: reviravoltas do mundo da vida. Petrópolis: Vozes, 2022., p. 11) observes that the digitalized and computerized world reflects the opposite of the terrestrial order - which “consists of things that take on a permanent form.” According to the author, the digital order decodes the world by informatizing it. It is the world of non-things. “These non-things are called information” (Han, 2022HAN, B-C. Não coisas: reviravoltas do mundo da vida. Petrópolis: Vozes, 2022., p. 12). Information on the digital world determines the lifeworld, the world of people. They appear as fast as they disappear. They are fleeting. However, it is known that when a piece of news disappears from a website, its deleterious effects may not disappear with it. Most commonly, when it comes to public management, these effects cause political and personal damage and, possibly, suffering in the lives of public managers.

In this scenario, managing the SUS became a risky activity, as can be seen in the words of one of the interviewees:

An analysis of all the testimonies showed a certain amount of hurt among managers, as they are often blamed for legal proceedings that have not yet been concluded. According to them, the process needs to be brought to an end, with evidence, before reputations are destroyed. In this area, among the various problems faced by managers is the increase in judicialization, with lawsuits arising especially from the insufficiency of beds in intensive care units and demands for high-cost medicines.

The scarcity of financial resources, a result of the process of reducing health system funding and deepened by the approval of Constitutional Amendment No. 95/2016 - which froze primary public spending for 20 years (Mendes; Carnut; Melo, 2023MENDES, A.; CARNUT, L.; MELO, M. Continuum de desmontes da Saúde Pública na crise do covid-19: o neofascismo de Bolsonaro. Saúde e Sociedade, São Paulo, v. 32, 2023. DOI: 10.1590/S0104-12902022210307pt
https://doi.org/10.1590/S0104-1290202221... ) - and the fragile working conditions of health professionals were also elements that caused tension among managers. According to those interviewed in our research, the vulnerability of managers in relation to the underfunding of the SUS and lawsuits at the time of the outbreak of the pandemic were determining factors for some managers to resign from their positions.

Despite the above and the finding that managers’ work is crossed by limiting factors, sources of tension, and frustration, it can be seen that the job is also a source of pleasure and motivation. It is in this sense that our interviewees, even in the midst of chaos, managed to grasp the importance of solidarity, empathy, and sharing among political actors. These factors were fundamental for the success of the strategies defined during the course of the pandemic and for strengthening the commitment made in defense of the population and the SUS itself:

We understand the solidarity announced both from an ethical dimension, which alludes to cooperation with the other, within a perspective of alterity, and from a legal dimension, uniting people from a perspective of the common and universal good, which even implies the development of concrete social and health public policies (Carvalho; Miranda, 2021CARVALHO, M. H. P.; MIRANDA, M. L. L. O princípio da solidariedade no enfrentamento da COVID-19 no Brasil. Cadernos Ibero-Americanos de Direito Sanitário, [s. l.], v. 10, n. 1, 2021. DOI: 10.17566/ciads.v10i1.729
https://doi.org/10.17566/ciads.v10i1.729... ).

For Harari (2020HARARI. Y. N. Na batalha contra o coronavírus, faltam líderes à humanidade. São Paulo: Companhia das Letras, 2020. , p. 10), like the pandemic, the lack of trust among human beings is also an acute crisis. Without wishing to disagree with the author, however, it seems appropriate to highlight the firmness of managers in affirming the importance of solidarity to save themselves and their respective managements. We agree with Carvalho and Miranda (2021CARVALHO, M. H. P.; MIRANDA, M. L. L. O princípio da solidariedade no enfrentamento da COVID-19 no Brasil. Cadernos Ibero-Americanos de Direito Sanitário, [s. l.], v. 10, n. 1, 2021. DOI: 10.17566/ciads.v10i1.729
https://doi.org/10.17566/ciads.v10i1.729... ) that the health crisis and its implications have made it urgent to build a society of salidarity and fraternity, with a convergence of actions. For the authors, it is “essential to build new paths or bridges for everyone to act in solidarity, individually and collectively, in a true pact of solidarity, in the sense of finding, by the union of forces, paths of overcoming” (2021, p. 9).

Final considerations

The SES is the direct public administration body of the state government that is responsible for developing the state health policy. In the midst of all the challenges that are part of the daily life of the SUS, the COVID-19 pandemic became the focus of attention in 2020 and 2021. The context forced managers to constantly plan and replan their resources and actions in the face of the unfolding of the pandemic and the challenges posed by the dismantling of the SUS and the political clashes, especially with the federal government. The moments of tension and conflict experienced by the managers during this period had political implications, but also personal ones, translated into mental suffering, anxiety, anguish, and stress.

The consequences of COVID-19 on society and health workers have already been studied from various angles. However, the participation and role of SUS managers, protagonists in one of the most delicate contexts of the institution, has not yet been sufficiently studied, nor have the repercussions of the context on the lives of these actors. In this sense, the evidence provided by this article offers a new perspective. Its results will certainly put the discussion about the health of SUS managers on the agenda, as well as the weaknesses and strengths of SUS management during the pandemic.

References

Publication Dates

History