ABSTRACT

The study analyzes the implementation process of public policy directed to the hypertensive and diabetic patients in the city of Venda Nova do Imigrante (ES), with the analysis focused on the determinants of institutional policy (strategy, structure, decision and identity) addressed by Strategor (2000). We sought to identify in this process of implementation the issues that enabled its successful outcome, as well as the potential to influence other similar experiences. The collective participation, professional autonomy, co-responsibility and the democratic decision by the interaction between managers and health professionals contributed to the implementation of such policy.

KEYWORDS
Public policies; Health public policy; Qualitative analysis

Introduction

Health services' management is complex due to the extent of this field and the need to merge individual, corporate and collective interests that are not always convergent (TAKAKI, TAMAKI, 2012).

With the decentralization of the Unified Health System (SUS) management, this complexity became more evident, since each Brazilian municipality, especially small towns, present their own singularities and specific management models. The formulation of health policies is strongly induced by the federal government, through the transfer of resources to states and cities for the admission and implementation of public policies (ARRETCHE, 2003ARRETCHE, M. Financiamento federal e gestão local de políticas sociais: o difícil equilíbrio entre regulação, responsabilidade e autonomia. Ciênc. Saúde coletiva, Rio de Janeiro, v. 8, n. 2, p. 331-345, 2003.; MARQUES; MENDES, 2003MARQUES, R. M.; MENDES, A. Atenção Básica e Programa de Saúde da Família (PSF): novos rumos para a política de saúde e seu financiamento? Ciênc. saúde coletiva, Rio de Janeiro, v. 8, n. 2, p. 403-415, 2003.). Thus, some successful experiences stand out in the national scenario, such as in the city of Venda Nova do Imigrante (ES), which in 2011 was recognized by the Ministry of Health (MS) and the Inter-American Development Bank (IDB), for successfully implementing a policy for hypertensive and diabetic patients. It is worth noting that the implementation of public policies occurs through their conversion into programs, projects and plans that will guide their conduction (SILVA; MELO, 2000SILVA, P. L. B.; MELO, M. A. B. O processo de implementação de políticas públicas no Brasil: características e determinantes da avaliação de programas e projetos. Núcleo de Estudos de Políticas Públicas: Unicamp, 2000. (Caderno, 48). Disponível em: <http://governancaegestao.files.wordpress.com/2008/05/teresa-aula_22.pdf>. Acesso em: 15 jun. 2013.
http://governancaegestao.files.wordpress... ).

This article analyzed the implementation process of the System for Registration and Monitoring of Hypertensive and Diabetic Patients (Hiperdia) in the city of Venda Nova do Imigrante between 2002 and 2010, based on the institutional policy determinants addressed by Strategor (2000)STRATEGOR. Política Global da Empresa: estratégia, estrutura, decisão, identidade. 3. ed. atual. Lisboa: Dom Quixote, 2000.. The discussion of this experience and the identification of the institutional policy determinants that were present in the process, could serve as basis for the strengthening of other health policies.

This qualitative study sought to deepen the discussion about the importance of understanding public policies' implementation processes, as well as to deliver a new analysis approach, by using institutional policy determinants at the municipal/local level.

It should be noted that, although public policy analysis and evaluation explore the same central objective (public policy), they are not synonyms and should be treated differently (SILVA; MELO, 2000SILVA, P. L. B.; MELO, M. A. B. O processo de implementação de políticas públicas no Brasil: características e determinantes da avaliação de programas e projetos. Núcleo de Estudos de Políticas Públicas: Unicamp, 2000. (Caderno, 48). Disponível em: <http://governancaegestao.files.wordpress.com/2008/05/teresa-aula_22.pdf>. Acesso em: 15 jun. 2013.
http://governancaegestao.files.wordpress... ). The analysis of public policies focuses on the State's public action, its determinants, purposes, processes and consequences. On the other hand, the evaluation of policies by revealing the political and ideological principles that guide the State's action, the relationships established among the demanding groups, the role of public institutions, the established government practices, and several other variables that influence the construction of a policy, allow for greater transparency about the political and decision-making pattern adopted by the State (VIANA; BAPTISTA, 2008VIANA, L. A.; BAPTISTA, T. W. F. Análise de políticas de Saúde. In: GIOVANELLA, L. (Org.). Políticas e Sistema de Saúde no BrasilRio de Janeiro: Fiocruz , 2008. p. 65-105.).

Material e methods

The methodology used in the study was based on 'Strategor Política Global da Empresa' by the Strategor Study Group, consisting of professors from the Strategy and Business Policy Department of the Hautes Études Commerciatres group in Jouy-en-Josas, France. This method aims to analyze the public policies' implementation process, in order to understand its intrinsic determinants.

Strategor's approach divides institutional policy into four major areas: decision, structure, identity, and strategy. These stages do not occur at different and segmented moments; they are instead a didactic-methodological division to better understand the content (DALFIOR; LIMA; ANDRADE, 2015ADALFIOR, E. T.; LIMA, R. C. D.; ANDRADE, M. A. C. Implementação de políticas públicas: metodologia de análise sob o enfoque da política institucional. Saúde debate, Rio de Janeiro, v. 39, n. esp., p. 283-297, dez. 2015a.).

Decision: is the main driver of institutional policy. Although the least visible, is through decisions that ideas, feelings and ambitions are transformed into strategic actions. Changes occurring within an institution are the result of decision-making processes (STRATEGOR, 2000STRATEGOR. Política Global da Empresa: estratégia, estrutura, decisão, identidade. 3. ed. atual. Lisboa: Dom Quixote, 2000.).

Structure: for Strategor (2000)STRATEGOR. Política Global da Empresa: estratégia, estrutura, decisão, identidade. 3. ed. atual. Lisboa: Dom Quixote, 2000. the structure is a set of rules that formally determine the missions that each institutional unit must carry out and the types of collaboration among them. In a simplified way, the structure can be represented by the institution's organization chart. Health services have structural characteristics different from other types of institutions. Because it is a professionally characterized structure, these operational centers have autonomy in deciding their actions. Each operational center is distinguished by its own standards, procedures and users (RIVERA, ARTMANN, 2006RIVERA, F. J. U.; ARTMANN, E. Planejamento e gestão em saúde: flexibilidade metodológica e agir comunicativo. In: ______. Análise estratégica em saúde e gestão da escuta. Rio de Janeiro: Fiocruz, 2006.).

Identity: one of the most complex determinants of institutional politics, the identity deals with human conditionalities present in all institutions. It is precisely it this area that the power influences takes place. The identity is what allows or not collaboration between the involved players, especially those in the operational centers, for a given strategy to be put into practice (STRATEGOR, 2000STRATEGOR. Política Global da Empresa: estratégia, estrutura, decisão, identidade. 3. ed. atual. Lisboa: Dom Quixote, 2000.).

Strategy: consists of the integration among the three previous determinants. The strategy, within this context, can be seen as the choice of the activity on which the institution will apply its resources for consolidation and development. Strategy definition is related to a self-recognition of potentials and weaknesses, identifying which fields or areas of action the institution has the greatest strength. Also, it is necessary to especially understand the external environment, identifying threats and opportunities. After this recognition process, the strategy will guide the institution on how best to apply its resources to remain competitive. In general, the strategy will direct the institution in identifying its mission, and its reason for existence (STRATEGOR, 2000STRATEGOR. Política Global da Empresa: estratégia, estrutura, decisão, identidade. 3. ed. atual. Lisboa: Dom Quixote, 2000.).

The town of Venda Nova do Imigrante is located in the mountain region of the state of Espírito Santo, at 100 km from the state capital Vitória, with a population of 20,447 inhabitants (IBGE, 2010INSTITUTO BRASILEIRO DE GEOGRAFIA E ESTATÍSTICA (IBGE). Dados do Censo, [Internet]. Brasília, DF: IBGE, 2010. Disponível em: <http://www.ibge.gov.br/cidadesat/topwindow.htm?1>. Acesso em: 28 jul. 2012.
http://www.ibge.gov.br/cidadesat/topwind... ). In 2010, the town had five healthcare units, three with Family Healthcare Strategy (ESF) teams and two with the traditional model, as well as total coverage of the Community Health Agent (ACS) program.

The study comprised the following methodological model: documentary analysis, using secondary data sources available in the SUS Information Systems (Datasus) and documents from the Municipal Health Department (health plans, management reports, indicators reports, among others); and semi-structured interviews with the main players involved in the implementation of the municipal Hiperdia policy including one municipal healthcare assistant, one healthcare surveillance coordinator, one control, evaluation and audit coordinator, and three healthcare professionals.

The interviews took place from September to December 2013 and sought to identify in the speeches the center meanings within each of the four determinants of institutional policy that were significant to the study objective. We used content analysis that includes pre-analysis, content exploration and processing of results (MINAYO, 2001MINAYO, M. C. S. Pesquisa social: teoria, método e criatividade. Petrópolis: Vozes, 2001.).

The study was approved by the Ethics Committee via Plataforma Brasil, protocol no. 324,895.

Results and discussion

One of the methods used in public policy analysis is the policy cycle, which organizes the policy process into stages, consisting of: construction of the policy agenda; policy formulation; decision-making process; policy implementation; and policy evaluation (BAPTISTA; REZENDE, 2011BAPTISTA, T. W. F.; REZENDE, M. A ideia de ciclo na análise de políticas públicas. In: MATTOS, R. A.; BAPTISTA, T. W. F. (Org.). Caminhos para análise das políticas de saúdePorto Alegre: Rede Unida, 2011. p. 138-172.; NAJBERG; BARBOSA, 2006NAJBERG, E.; BARBOSA, N. B. Abordagens sobre o processo de implementação de políticas públicas. Revista do Centro de Ciências Sociais Aplicadas, São Paulo, v. 3, n. 2, p. 31-45, jul./dez. 2006.; VIANA; BAPTISTA, 2009VIANA, L. A.; BAPTISTA, T. W. F. Análise de políticas de Saúde. In: GIOVANELLA, L. (Org.). Políticas e Sistema de Saúde no BrasilRio de Janeiro: Fiocruz , 2008. p. 65-105.; RIBEIRO, 2009RIBEIRO, J. L. L. S. A avaliação como uma política pública: aspectos da implementação do SINAES. In: LORDÊLO, J. A. C.; DAZZANI, M. V. (Org.). Avaliação educacional: desatando e reatando nós. Salvador: Edufba, 2009. p. 57-84.). In this study, the emphasis was in the implementation stage, considered the crucial moment of the policy cycle, in which the proposals are converted into institutionalized action. In this stage, government actions and projects, which had been extensively analyzed within the local context, are put into practice (DALFIOR; LIMA; ANDRADE, 2015b______. Reflexões sobre análise de implementação de políticas de saúde. Saúde debate, Rio de Janeiro, v. 39, n. 104, p. 210-225, mar. 2015b.).

Thus, the results are presented and discussed considering the analysis of the implementation process of the Hiperdia policy on: 1) the decision-making process; 2) the institutional structure; 3) the identity of the municipal health department and 4) the formation of the municipality's institutional strategy.

The decision-making process

Within the Municipal Health Department of Venda Nova do Imigrante (Semus/VNI), our findings showed that the implementation process of the Hypertension (HT) and Diabetes Mellitus (DM) service (Hiperdia), began with an initiative of the municipal administration, encouraged by the Office of Welfare of the State of Espirito Santo (SESA) through a debate on Illnesses and Noncommunicable Diseases (Dant), and by the federal government.

The morbidity and mortality data for the city were fundamental in the decision process, since they were perceived by both healthcare managers and professionals. "We had very high mortality rates. There were many deaths because of cardiovascular diseases, and many hospital admissions" (Manager 1).

The speeches indicate that there is a gap between the assistance domain and the managing domain, as described by Rivera and Artmann (2006)RIVERA, F. J. U.; ARTMANN, E. Planejamento e gestão em saúde: flexibilidade metodológica e agir comunicativo. In: ______. Análise estratégica em saúde e gestão da escuta. Rio de Janeiro: Fiocruz, 2006.. Managers emphasized health indicators and the cost of medicines as main factors in the decision-making process, focusing more on economic and quantitative criteria. On the other hand, health professionals focused more on qualitative criteria and on issues that directly affect the care provided to the patient.

After acknowledging the problem, the definition of a strategy began to take place. However, the decision-making process is not a simple or individualistic action. Problems caused by collective decisions need to be accounted for, especially in institutions organized under the professional approach where a strong autonomy exist, such as the healthcare services. Any decision taken within an institution reflects on all areas. Hence the complexity of the decision-making process.

The first step taken by Semus/VNI regarding their institutional planning, was focused on the healthcare plan that pointed out the guidelines for HT and DM. The planning was defined based on an intended image of the future welfare. Nevertheless, how to accomplish this was not defined.

The documents that formalized these global decisions were the Municipal Health Plans (PMS) 2002-2005 and 2006-2009, which set goals and actions regarding HT and DM, especially directed to reducing their complications, based on the Health indicators (VENDA NOVA DO IMIGRANTE, 2001VENDA NOVA IMIGRANTE. Plano Municipal de Saúde 2002-2005. Venda Nova Imigrante: Secretaria Municipal de Saúde, 2001.).

The national policy aimed at patients with HT and DM, in a regular situation, is a top-down health policy imposition. The people involved in decision-making regarding policies' priorities not always are familiar with local characteristics, which can result in the non-implementation of the policy, or even prevent the achievement of the objectives set in the policy (VIANA; BAPTISTA, 2009VIANA, L. A.; BAPTISTA, T. W. F. Análise de políticas de Saúde. In: GIOVANELLA, L. (Org.). Políticas e Sistema de Saúde no BrasilRio de Janeiro: Fiocruz , 2008. p. 65-105.).

Despite this, the results showed that professionals at Semus/VNI assumed a position that averted the imposition of the policy implementation. According to the interviewees, this was a result of the 'strategic management' adopted by the administration, which decreased the distance between the strategic centers (managers) and the operational centers (healthcare professionals). Thus, the decision-making process created a collegial and participatory management model. This approximation was anchored in the decision-making power disseminated by the institution, and not centered on the manager/director. Consequently, the managers guided the institutional project, but the implementation strategy was defined by all players involved, at all levels of the system.

A very close correlation between the decision process and the structure of the system is observed in the interviewees' statements. When analyzing this relationship, particularities of the Hiperdia implementation process are revealed. In general, the structure is related to the responsibilities and infiltrating power within the institution. Thus, the structure contributes to the choices, which are based on how players deal with problems, since decisions go beyond rational approaches or internal norms (STRATEGOR, 2000STRATEGOR. Política Global da Empresa: estratégia, estrutura, decisão, identidade. 3. ed. atual. Lisboa: Dom Quixote, 2000.). For an effective professional participation in management instances, collaborating to develop the autonomy of professionals in health services would be one of the objectives of a health policy. This autonomy would allow the subjects a greater capacity to understand and take action upon themselves and the context, according to democratically established goals (CAMPOS, 2009CAMPOS, R. T. O.; CAMPOS, G. W. Co-construção de autonomia: o sujeito em questão. In: CAMPOS, G. W. et al (Org.). Tratado de Saúde Coletiva 2. ed. São Paulo: Hucitec, 2009. p. 669-688.).

The autonomy of the health professionals in defining the strategy and the actions for Hiperdia implementation was essential for the effectiveness of the work. The health professionals assumed the technical guidance of the discussions, as they had the knowledge to organize the healthcare network.

From the meetings between managers and health professionals, the elaboration of a municipal protocol focused on hypertensive and diabetic patients was initiated, called the Municipal Protocol of Hypertension and Diabetes. This protocol was the means to address some of the problems, especially the organization of the municipal care network for patients with HT and DM. Its adoption was decided collectively, in which all involved could collaborate with their suggestions in defining the actions that would be taken. This setting is known as co-management (Campos, 1998CAMPOS, G. W. S. O anti-Taylor: sobre a invenção de um método para co-governar instituições de saúde produzindo liberdade e compromisso. Cad. Saúde Pública, Rio de Janeiro, v. 14, n. 4, p. 863-870, out. 1998.), in which everyone decides, deliberating with other instances of power on conflicting interests, based on permanent negotiation, discussion and re-composition of other needs and interests.

The success of policy implementation depends on links between different organizations and departments at the local level (SOLLA, 2010SOLLA, J. Dilemas e desafios da gestão municipal do SUS. São Paulo: Hucitec, 2010.). Thus, the implementation requires high cooperation, which if absent can result in the buildup of small deficits creating a major failure of the process.

In healthcare institutions, the power is decentralized in the hands of the various players (MINTZBERG, 2009MINTZBERG, H. Criando organizações eficazes: estrutura em cinco configurações. 2. ed. São Paulo: Atlas, 2009.). This power is understood, according to Testa (1995)TESTA, M. Pensamento estratégico e lógica de programação: o caso da saúde. São Paulo; Rio de Janeiro: Hucitec; Abrasco, 1995., as fluid and part of project disputes in the institutions. The power originates from the ability to accumulate resources in disputes, depending on the position and negotiations of the various players, in various and complex dimensions of technical, administrative and/or political instances. Enabling the participation of players in the decision-making process is a way of strengthening partnerships and synergies.

Thus, the collective recognition of the issues associated with HT and DM was based on the analysis of the internal and external environments and acting critically on them, especially for the development of synergies and partnerships. The involvement of professionals in the Family Healthcare Strategy (ESF), in specialized care (particularly cardiologists and endocrinologists), in health surveillance, in laboratories, in pharmaceutical assistance and managers was essential for the healthcare network organization.

In the decision-making process, the interviews showed in general that the meetings stimulated a collective reflection on problems collectively identified, which contributed to a sense of co-responsibility of the problems and their possible solutions. The decision-making power was established based on the transversality and interdependence of the participants, as a results of increased communication between members of each group, and between the different groups, in a multi-direction network dynamics, in which health production processes and subjectivity are expressed.

In addition, strategic management allowed individual strategies to be combined into a collective strategy, facilitated by the meetings and the open management allowing the discussion with professionals on how best to solve the problems. It should be emphasized that, within a shared vision proposed by Peter Senge, it is up to the manager to try to design and develop continuous processes in which people at all functional and hierarchical levels feel free to express what really matters to them, or in other words, the content of a shared vision can only emerge through a coherent process of reflection and conversation (RICHE; MONTE ALTO, 2001RICHE, G. A.; MONTE ALTO, R. M. As organizações que aprendem, segundo Peter Senge: A quinta disciplina. Cadernos Discentes Copped, Rio de Janeiro, n. 9, p. 36-55, 2001.).

The institutional structure

A direct relationship between structure and strategy is fundamental, since the understanding of the institutional mission is important for both. In order to achieve a positive response of the institution to the objectives outlined, a less normalized structure, set up based on results would be recommended, taking advantage of the potential of each player within the process, in a participatory and collective way.

The traditional management models in health services still carry traits of Taylorism, where power is centered on bosses with direct control over the performance of technical procedures (medical productivity, etc.) and formal employee behavior (time schedule compliance, reports, etc.). Moreover, the model is characterized by the centralized elaboration of programs and service regulatory norms and by virtual absence of communication between services in horizontal power relations and between the different hierarchical levels (CAMPOS, 1998CAMPOS, G. W. S. O anti-Taylor: sobre a invenção de um método para co-governar instituições de saúde produzindo liberdade e compromisso. Cad. Saúde Pública, Rio de Janeiro, v. 14, n. 4, p. 863-870, out. 1998.).

In order to analyze the implementation process from the perspective of the institutional structure, it is necessary to understand the Semus/VNI organization. Based on the analyzed documents, it was observed that its structure is quite horizontal, lacking hierarchical divisions, with the municipal secretary of health and the municipal health council sharing the highest managing position, followed by the managers of units and services, and it has few coordination divisions. This type of structure may have contributed to the approximation and discussion among professionals in the sectors, as well as to a less rigid coordination.

It is important to emphasize, from the institutional learning perspective according to Senge (1994)SENGE, P. M. et al. A quinta disciplina - caderno de campo: estratégias para construir uma organização que aprende. Rio de Janeiro: Qualitymark, 1994., that structures should not be visualized individually, fragmented and isolated ignoring the underlying structures, as this would lead to weaknesses in more complex situations. According to Rivera and Artmann (2006)RIVERA, F. J. U.; ARTMANN, E. Planejamento e gestão em saúde: flexibilidade metodológica e agir comunicativo. In: ______. Análise estratégica em saúde e gestão da escuta. Rio de Janeiro: Fiocruz, 2006., negotiation and communication strategies adopted by management, contrary to the mechanistic normalization of the process, are used as a means for the consolidation of normative deals that favors cohesion in healthcare institutions. The management system in healthcare institutions should strengthen mutual adjustment and negotiation of interests, characterized by healthcare professional authority, diffused and strongly shared, or distributed by the various operational and professional centers.

The Municipal Health Department identity

Institutions are crossed by explicit or implicit values closely linked to institutional identity that guide decisions and rules. A strategy definition is based on these values, which are determined by beliefs about human nature and the world, resulting from experience, education and personal reflection. Moreover, values are influenced by existing legal norms, by the social principals of each historical instant, by cultural tradition, by a set of ideas, knowledge, customs, habits, aptitudes, symbols and rites that are present in the institutional culture. It is the adoption of values that drives dignity protection and promotion from the institutional mission of the healthcare services (ZOBOLI; FRACOLLI, 2006ZOBOLI, E.; FRACOLLI, L. A incorporação de valores na gestão das unidades de saúde: chave para o acolhimento. Mundo da Saúde, São Paulo, v. 30, n. 2, p. 312-317, 2006.).

The speeches, especially of health professionals, indicate a recognition of the institutional mission, as people assumed a protagonist role in the strategy definition, sharing responsibility for the actions and for the results achieved.

The statements of professionals and managers reinforce that there was a commitment and co-responsibility of all involved, at all levels, resulting in a strong autonomy to decide on the actions to be performed.

The results achieved with the implementation of Hiperdia, as reported by the players, demonstrated a personal and emotional involvement. These characteristics go beyond quantitative and economic issues, creating an identity and guaranteeing integration. Also, they move away from formal mechanisms of hierarchical coordination, and towards mechanisms based on recognized and legitimized collective interdependence among the actors. In the Hiperdia implementation process, there was management initiative added to the autonomy and the involvement of the health professionals.

The institutional strategy development

In this study, strategy was defined as the way, process, and actions conduction to implement Hiperdia, that is, to the settings and choices of each action until their results. The whole process is part of the formation of the institutional strategy formation.

It is important to highlight that the focus of this study is the implementation of Hiperdia, not an overall analysis of the institution. Therefore, the mission applied only to the Hiperdia municipal policy.

The results showed that the Semus/VNI strategy formation was based on the participatory discussion among all the actors involved. Through meetings, facilitated by strategic management, by the existing structure and by the identity of the professionals involved, the paths to address the problems identified in the city were traced resulting in the implementation of the policy and especially in the construction of the care network for HT and DM.

From the decision to develop a protocol, it was necessary to adapt the policy to the municipal reality.

The analysis of the internal and external environment identified the main problems, such as the lag of the national protocol, the difficulties of policy adaptation to the municipal reality, high morbidity and mortality indicators, lack of work standardization, among others. The team prioritized the problems by importance and conditions for addressing each problem, and thus, planned the elaboration of the protocol.

The analysis of the municipal context had the active participation of all the actors involved, using information made available by the management, municipal indicators, as well as the problems reported by health professionals. The simple identification of the problem was not enough to plan a solution proposal; the team had to classify it as a priority.

The existing structure stimulated the discussions to change reality. Once the strategy was defined, the structure was also modified to accommodate what was decided by the actors.

The way the implementation of Hiperdia was organized can then be considered a competitive differential, which gave Semus/VNI an advantage over other municipalities. In other words, the strategy used, such as linking, partnerships and synergies, was the competitive advantage that made possible the implementation of the Hiperdia care network.

The consolidation of Hyperdia allowed greater effectiveness in the performance of exams, provision of medications, and diagnostic tests, based on the actual patient need. All of these benefits translate into the recognition and effectiveness of the institution's internal costs, although this was not explicit in the interviews. On the other hand, the organization of the work process, facilitated by the implementation of the protocol, may have contributed to reduce costs and ensure greater performance efficiency. For patients, this strategy may have ensured the continuity of treatment and fewer complications from these conditions.

The healthcare provision model has some of the relevant obstacles of a health system. An important point that has been discussed is the inversion of a health 'assistance' paradigm (medico-centered) to a paradigm focused on health promotion and disease prevention and aimed at primary care. In the Hiperdia implementation, the regulation of diagnostic and clinical-therapeutic support resulted in resource efficiency (exams, medications, professionals, supplies), as well as reduced specialist referrals, hospitalizations and complications. The multi-professional attention (nutritionists, physical educators, biochemists, pharmacists, community health agents, nurses, physicians, etc.) allowed for greater patient control and monitoring, which may have resulted in improved efficiency and productivity, fully recognized by the members of the process.

The mission of this municipal policy, although not explicit, can be identified in the interviewees' statements, as the reduction of cardiovascular diseases complications, which was the major objective that drove the actions. This resulted from collective participation, professional autonomy, co-responsibility and democratic decision, through the interaction between managers and health professionals, in a collective learning paradigm.

The role of management in this process points to the capacity for collective leadership, which may have ensured greater relevance to the people involved. According to Rivera (2003)RIVERA, F. J. U. Planejamento e gestão em saúde: flexibilidade metodológica e agir comunicativo. In: ______. Análise estratégica em saúde e gestão pela Escuta. Rio de Janeiro: Fiocruz, 2003. p. 17-35., to achieve professional responsibility towards an institutional mission, leadership must translate in the democratization of decisions and intersubjective understanding, i.e., rather than defend its own vision the leader should allow everyone involved a chance for free argumentation and consensus-based decision-making.

This collective construction suggests that the planning of policies and strategies involves a process of communicative institutional learning (RIVERA, 2003RIVERA, F. J. U. Planejamento e gestão em saúde: flexibilidade metodológica e agir comunicativo. In: ______. Análise estratégica em saúde e gestão pela Escuta. Rio de Janeiro: Fiocruz, 2003. p. 17-35.). In this perspective, the ideal management, according to Riche and Monte Alto (2001)RICHE, G. A.; MONTE ALTO, R. M. As organizações que aprendem, segundo Peter Senge: A quinta disciplina. Cadernos Discentes Copped, Rio de Janeiro, n. 9, p. 36-55, 2001., should be one in which people, at all levels, commit to the institutional project and to a desire for knowledge. Thus, the key is not achieving the right strategy, but promoting strategic thinking, and one of the tasks of the leader should be precisely to promote a learning environment by the dissemination of this model (RIVERA, 2003RIVERA, F. J. U. Planejamento e gestão em saúde: flexibilidade metodológica e agir comunicativo. In: ______. Análise estratégica em saúde e gestão pela Escuta. Rio de Janeiro: Fiocruz, 2003. p. 17-35.).

For Peter Senge (1994)SENGE, P. M. et al. A quinta disciplina - caderno de campo: estratégias para construir uma organização que aprende. Rio de Janeiro: Qualitymark, 1994., institutions that achieve learning are made up of individuals who continually express their ability to create the results they desire. In these institutions, new and expansive behavior patterns are encouraged, in which collective goals gain freedom and people continually practice collective learning. This process can be considered a sustainable competitive advantage.

Final considerations

Implementation of public policies has shown to be a broad field, represented by complex networks composed of different actors, and a learning process in which these actors agree and articulate among themselves, creating new ways of practicing.

The methodology used in this study, adapted from the Strategor framework, allowed the analysis of the Hiperdia implementation process in a broad manner, considering issues that go well beyond statistical data, usually used in institutional evaluations. As a limitation of the Strategor framework, its structured analysis stands out, which can be confused with a 'set of rules'. However,

In addition, this referential is based on collegial meetings with the objective of promoting a broad communication focusing on a cultural change, which requires time and depends on variables such as greater political and administrative stability. Finally, since the modification of practices also refers to historical facts, and not to the action of out-of-context variables, the framework used does not allow to confirm the continuity of such changes.

The experience in Venda Nova do Imigrante points to an institution that 'learns', since its participants are capable of creating the needed results. Strategic management encouraged all actors to collectively seek new and more comprehensive patterns of behavior based on joint aspirations with freedom to practice collective learning. According to Senge (1994)SENGE, P. M. et al. A quinta disciplina - caderno de campo: estratégias para construir uma organização que aprende. Rio de Janeiro: Qualitymark, 1994., the ability to learn continuously and rapidly is the only sustainable competitive advantage.

The results display the power of this referential for the analysis of public policies implementation process,

According to these authors, this broader range of analysis of Strategor's framework points to

To tackle implementation problems and to account for their complexity, a strategic view of the problems is necessary as well as the incorporation of critical issues that reflect the feasibility of the policy and the problems with inter-institutional management. This methodological design allowed the identification of complex networks of local actors, such as formulators, implementers, people involved in politics and beneficiaries, who all provided political support and legitimacy. With this analysis, we captured implicit elements of the implementation process, confirming that the method is a powerful tool in understanding the process conduction and the factors that enabled to achieve a competitive advantage. Strategor's framework contributed to the identification of the process as a learning process. The conduction of this implementation process allowed us to uncover elements of the 'missing link' of governmental action.

References

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