ABSTRACT

This study aimed to analyze the experiences of career plans, positions and salaries awarded by the Ministry of Health. For this purpose, a descriptive and qualitative research was conducted, in 2013, through documentary analysis and interviews with managers of the health secretariats with implanted plans. Data were analyzed in the light of national guidelines for the establishment of plans in the Unified Health System. The studied plans, negotiated with the employees and based on the guidelines, consider performance evaluation and professional qualification for career progression. It is concluded that plans need to include the various types of employment bonds and forms of remuneration compatible with health careers.

KEYWORDS
Health manpower; Personnel management; Salaries and fringe benefits; Employee performance appraisal

Introduction

The national scenario of the brazilian health system points to a series of challenges, in relation to the management of health work. Some critical nodes have been debated for years, such as low pay, lack of motivation of the professionals, precariousness/flexibility of the employment bonds and difficulties in implementing strategies to reduce the worker's turnover.

In this context, according to the guidelines established for the human resources area (HR) in the Basic Operational Norm (NOB/RH-SUS), the Career Plan, Positions and Salaries (CPPS) is considered a work ordering tool, and should be incorporated in each level of management of the Unified Health System (UHS) (BRAZIL, 2005).

The CPPS can be defined as an instrument of work management, whose purpose is to value the worker and establish the career process in the institutions. Furthermore, it is a set of norms that guide and discipline the trajectory of the worker in his career, as well as the respective remuneration, promoting opportunities of professional qualification (CASTRO, 2012CASTRO, J. L. Saúde e trabalho: direitos do trabalhador da saúde. Revista de Direito Sanitário, São Paulo, v. 12, n. 3, p. 86-101, mar./jun. 2012.; BRAZIL, 2006______. Ministério da Saúde. Secretaria de Gestão do Trabalho e da Educação na Saúde. Protocolo nº 006/2006. Aprova as Diretrizes Nacionais para a instituição de Planos de Carreira, Cargos e Salários no âmbito do Sistema Único de Saúde - PCCS - SUS. Brasília, DF: Ministério da Saúde, 2006.).

In this sense, beyond the perspective of rights, it is understood that the career plan is a powerful management tool, especially when added to other subsidies, such as gratification, performance evaluation and progression by qualification (SEIDL , 2014SEIDL, H. et al. Gestão do trabalho na Atenção Básica em Saúde: uma análise a partir da perspectiva das equipes participantes do PMAQ-AB. Saúde em Debate, Rio de Janeiro, v. 38, n. esp. p. 94-108, out. 2014.).

Although guided since 1986 by the Health Reform Commission, and, then, by the Federal Law nº 8.080/90, the career plans in the UHS have only begun to be effectively promoted after the creation of the Secretariat of Work and Education Management in Health (SGTES) and reinstallation of the National Permanent Negotiation Table of the UHS (MNNP-SUS), in 2003 (BRAZIL, 1986______. Ministério da Saúde. Comissão Nacional da Reforma Sanitária. Bases para o aperfeiçoamento das ações integradas de saúde como estratégia para a reforma sanitária brasileira.Brasília, DF: Ministério da Saúde, 1986., ¹⁹⁹⁰______. 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: <http://www.planalto.gov.br/ccivil_03/leis/L8080.htm>. Acesso em: 3 mar. 2017.
http://www.planalto.gov.br/ccivil_03/lei... , ²⁰⁰³______. Ministério da Saúde. Secretaria de Gestão do Trabalho e da Educação na Saúde. Conselho Nacional de Saúde. Mesa Nacional de Negociação Permanente do SUS: democratização nas relações de trabalho no Sistema Único de Saúde SUS. Brasília, DF: Ministério da Saúde , 2003. (Série D. Reuniões e Conferências). Disponível em: <http://bvsms.saude.gov.br/bvs/publicacoes/livreto_mesa.pdf>. Acesso em: 3 mar. 2017.
http://bvsms.saude.gov.br/bvs/publicacoe... ).

Then, in 2006, the Guidelines of the Career Plan, Positions and Salaries were approved in the scope of the UHS, to support the construction of plans at the regional, state and municipal levels, considering the particularities of the local systems (BRAZIL, 2006______. Ministério da Saúde. Secretaria de Gestão do Trabalho e da Educação na Saúde. Protocolo nº 006/2006. Aprova as Diretrizes Nacionais para a instituição de Planos de Carreira, Cargos e Salários no âmbito do Sistema Único de Saúde - PCCS - SUS. Brasília, DF: Ministério da Saúde, 2006.).

In 2012, to value the proposals of plans established by local systems, but also to promote new propositions, the Ministry of Health launched a public notice for the InovaSUS project, with the theme Career: Career Plans, Positions and Salaries (InovaSUS-Carreira), awarding 12 projects (BRAZIL, 2015______. Ministério da Saúde. Secretaria de Gestão do Trabalho e da Educação na Saúde. Prêmio InovaSUS 2012/2013: valorização de boas práticas e inovação na gestão do trabalho na saúde. Brasília, DF: Ministério da Saúde, 2015. Disponível em: <http://portalarquivos.saude.gov.br/images/pdf/2015/maio/21/livro-inovasus-2012-2013-21052015.pdf>. Acesso em: 3 mar. 2017.
http://portalarquivos.saude.gov.br/image... ). Created in 2011, the InovaSUS was the first innovation award related to the management of the health work. The initiative aims to value experiences in the area, with the awarding of projects that seek excellence, improve the quality of services, working conditions and service to the UHS users, and demonstrate possibilities of replication (BRAZIL, 2015______. Ministério da Saúde. Secretaria de Gestão do Trabalho e da Educação na Saúde. Prêmio InovaSUS 2012/2013: valorização de boas práticas e inovação na gestão do trabalho na saúde. Brasília, DF: Ministério da Saúde, 2015. Disponível em: <http://portalarquivos.saude.gov.br/images/pdf/2015/maio/21/livro-inovasus-2012-2013-21052015.pdf>. Acesso em: 3 mar. 2017.
http://portalarquivos.saude.gov.br/image... ).

In view of the exposed, and in order to produce evidences that may support the structuring and/or updating of career plans, this study aimed to analyze experiences of implementation of the CPPS awarded by the InovaSUS-Carreira, having as reference the national guidelines elaborated and approved by MNNP-SUS.

Material and methods

This study is an unfolding of the research 'Evaluation of national policies and programs of the health work and health management in the UHS', finalized in 2014, in which 519 managers of state and municipal health secretariats were interviewed (here called SHS and MHS, respectively), with the objective of identifying the stage and the capillarity of work management policies (OBSERVARH-IMS/UERJ, 2014OBSERVATÓRIO DE RECURSOS HUMANOS EM SAÚDE (OBSERVARH-IMS/UERJ). Estação de Trabalho Instituto de Medicina Social da Universidade do Estado do Rio de Janeiro. Avaliação de Políticas e Programas Nacionais da Gestão do Trabalho e da Educação em Saúde no SUS. Rio de Janeiro: ObservaRH-IMS; UERJ, 2014. Disponível em: <http://www.obsnetims.org.br/uploaded/11_5_2015__0_Sumario_Executivo_Avaliacao_de_Politicas_e_Programas_Nacionais.pdf>. Acesso em: 3 mar. 2017.
http://www.obsnetims.org.br/uploaded/11_... ).

In the possession of the results of the research, which indicated a deficiency in the valorization policy of the worker, with few career plans instituted within the UHS, it was decided to identify and analyze successful experiences of CPPS implementation.

It is a descriptive and analytical study, with a qualitative approach, whose object of analysis were some experiences of CPPS implantation.

In order to determine the experiences to be investigated in depth, the results of the 2nd edition of the InovaSUS-Carreira Award were considered, awarding 12 initiatives, implemented or not, considered of excellence. Data collection took place in two stages. First, documents were collected regarding the plans of the awarded structures (legislation, instruments and projects presented at the time of application for the InovaSUS-Carreira) and secondary data for the characterization of the scenarios. In the second stage, eight health secretariats were selected, since they were constituted as large size state or municipal structures (over 500 thousand inhabitants), and because they had implemented the award-winning CPPS, namely: state secretariats of Mato Grosso, Bahia, Tocantins and Alagoas; the State Foundation for Family Health (Fesf) of Bahia (Fesf-BA); and the municipal secretariats of Goiânia, Recife and Guarulhos.

Once the structures were selected, telephone contact was made with the local managers, responsible or participants in the CPPS implementation process, to schedule an in loco interview. 13 managers participated in the study.

For this phase, a semi structured data collection instrument was manufactured, based on the national guidelines for the establishment of CPPS within the scope of the UHS, elaborated and approved by MNNP-SUS. The instrument contemplated 58 questions structured in 6 blocks: respondent identification; identification of the structure searched; process and implementation of the CPPS; characterization/structuring of the CPPS; performance evaluation; and open questions (opinionative).

The interviews, performed in august and september of 2013, were recorded in digital audio equipment and portable recorder, with integral transcription of the content.

The data deriving from the documents were submitted to a descriptive documentary and statistical analysis, from the database processing structured in Excel software. The information deriving from the interviews was treated by descriptive analysis, confronted with the national guidelines for the institution of CPPS within the scope of the UHS, selected documents and relevant literature. Posteriorly, the results of the research were presented for discussion and validation with the actors involved, members of the MNNP-SUS and representatives of SGTES.

According to ethical standards destined to researches involving human subjects, the study was submitted to the Research Ethics Committee of the Institute of Social Medicine of the Rio de Janeiro State University, and approved under the Presentation Certificate for Ethics Appreciation (CAAE) nº 0038.0259.000-11.

Results

Profile of the interviewees and characterization of the structures

From the total of 8 structures surveyed, 13 managers participated as respondents, including 8 women, corresponding to 61,5% of the sample. As for education, 12 of them have degrees in the most diverse areas: social service (n=3), law (n=2), administration (n=2), medicine, accounting sciences, nursing, computer technology and psychology.

Most of the managers (n=7) have, as the highest degree, the Specialization in Work and Education Management in Health, developed as a result of the training promoted by the adhesion to the Program for Qualification and Structuring of Work and Education Management in the UHS (ProgeSUS); five have master degree; and one has technical level training. Regarding the time of the managers in the positions, an average of 3,2 years was observed.

All the researched structures have specific organs for human resources, created at least five years ago, and are in the first or second echelon of the health secretariat.

Implantation of Career Plans, Positions and Salaries

In order to present the awarded CPPS, all the structures studied started from some plan already implemented, configuring it according to the national guidelines, preserving the necessary adaptations for each location. The exception was MHS from Guarulhos, which did not even present a general plan for municipal servers. Specific commissions were created with the participation of the workers, but most of the structures did not make the discussion in negotiation tables, for not having them implanted.

The time between the submission of a career proposal and its implementation was, at least, of one year, and, at most, of six years. For this purpose, financial impact studies were requested, in some cases, more than once, for the purpose of adequacy and feasibility of the plan.

Structural characteristics of the specific CPPS for the health sector

In terms of coverage, the greatest difficulties of inclusion are given to the administrative professionals, since there is the understanding, on the part of the superior management of the administrative department, that these professionals are 'systemic', that is, they are hired to work in any one of existing sectors within the municipality/state.

Only the SHS of Tocantins has all the effective health workers - about 11 thousand - included in the health CPPS, except for a few administrative employees, who chose to remain in the general list of the state. Fesf includes all the professionals hired by it, but there is no inclusion of the health agents, who are hired by the municipalities.

The health professionals of the state of Alagoas are distributed in nine distinct plans, three of them specific to the health: CPPS of the doctors; CPPS of health support professionals, winner of the InovaSUS Award, which includes all the planning, administration, transportation, and infrastructure headcounts in the sector; and CPPS of technicians, assistants and health aides, which includes all higher, middle and elementary health workers, except those who are framed in specific plans.

The MHS of Recife and Guarulhos, and the SHS of Bahia have a general plan for headcounts of health, which does not include administrative headcounts. This latter still has a specific plan for doctors. The plan of the SHS of Mato Grosso includes only part of the administrative. The MHS of Goiânia has two plans for health workers, and the award plan, implemented in 2012, includes all headcounts, but not the administrative headcount. The headcount implemented in 2004 only applies to health professionals who did not want to migrate to the new plan, but does not include the administrative headcount or health workers.

Regarding the predominance of professionals of some level of attention, many incongruities are not perceived, since the states have a higher number of professionals at the tertiary level, while the municipalities predominantly include Primary Health Care (PHC). The surprise is the Fesf, which today employs a greater number of professionals of the hospital scope, when it was expected to have a higher percentage of PHC professionals, since the initial proposal for its creation was to make feasible the expansion and consolidation of the Family Health Strategy (FHS).

This scenario is due, mainly, to the non-contracting process between Fesf and the municipalities that created it. Of the total of 69 municipalities that implemented it, only 16 remain with active contracts. Therefore, Fesf has extended services to other levels of complexity, other than primary.

With regards to the career advancement methods, mostly, the plans consider the process of performance evaluation and qualification. According to some respondents, not measuring the length of service at the time of joining the plan, in some cases, was unfavorable to many professionals, since many, when allocated on the expiry tables, were at the same level as other newly-admitted professionals or with shorter length of service. The main motivation for not accounting for length of service was largely due to the financial impact it would cause.

One of the bigger issues in the discussion and approval process of the proposals of the plans relates to gratuities and additional, with emphasis on the non-incorporation of the unhealthy addition to retirement. All the structures surveyed offer some additional, except for Alagoas, where there is, also, a movement of discussion about the real right of receiving the additional of insalubrity. In this state, the newly admitted professionals are not entitled to such benefit, unlike the servers already working. This fact has generated legal disputes and negotiations between the parties concerned.

This scenario identified in the state of Alagoas is already perceived in other instances, perhaps because the legislation that provides it is fragile in several aspects, allowing employers to resolve the impasses at the local level.

Other inquiries about unhealthiness refer to its accounting for purposes of overtime calculation, holidays and 13th salary. This is because the additional integrates the remuneration, but is not incorporated into retirement, being, therefore, an appeal plausible for the worker, as to the employer's refusal to consider it for this purpose.

Performance evaluation processes

All plans foresee a performance evaluation process, however, in the SHS of Alagoas, in the MHS of Recife and in the Fesf-BA there is still no legislation that regulates it. According to the respondents of the survey, the expected performance evaluation models cover all the employees of the structure, except for the Alagoas model (restricted to health support workers), and were negotiated with the workers, excluding Tocantins and the Fesf.

The periodicity, the requirements and forms of evaluation vary among the locals, it is also highlighted that the SHS of Bahia, because it has not yet regulated the parameters and indicators, executes a model in which the individual evaluation is based only on the worker's attendance.

The research data point to a great difficulty of regulating and developing a performance evaluation process that is not merely illustrative and bureaucratic, and whose results are analyzed to subsidize improvements to the service and to the development of processes of permanent education. Nevertheless, in some places, the performance evaluation guarantees significant additional remuneration for the worker, in the case of the Fesf and the MHS of Recife.

Potential and Critical Nodes of the CPPS of Health

About the current career plans, the chart 1 presents the main positive and negative points of the CPPS of health, according to the perceptions of the managers.

It is valid to draw attention to the implementation of a worker health policy in the states of Mato Grosso and Bahia. The managers exalted this initiative, as a result of negotiation and struggle of workers, as an important step in the fight against bad working conditions, diseases and injuries of the worker, coming from an unhealthy environment, high workload, scarcity of basic inputs, etc.

Still as points of relevance, stand out: movement of extinction of the social organizations in the state of Mato Grosso; proposal of unification of the countless plans existing in the scope of the state of Alagoas; evaluation of computerized performance, with specific instruments in interface with permanent education, in Tocantins; and difficulties for hiring doctors and nursing assistants by the MHS of Guarulhos.

Comparison between the CPPS and the national guidelines of the MNNP-SUS

The laws that implements and governs the plans are in accordance with what the guidelines predict, as already pointed out by the managers themselves. However, particularities can be noted, since the guidelines themselves are generic for each local to suit their reality.

One aspect to be highlighted is the scope of the plan. The guidelines indicate that all UHS workers are framed in CPPS. Despite this, there are disparities between the sites, in view of the understanding, by some managers/governors, that some positions are generic in the areas of the city hall and state, so that professionals occupying such positions can act in any sector, being liable, therefore, to adhere to a general framework of the body.

Another point to be discussed is in relation to the division of classes, which national guidelines propose to be performed according to the level of schooling, constituting, for example, a generic class/position for all professionals with higher level. Although the plans studied have tried to stick to what the guidelines recommend, this aspect was considered a nerve center, given the difficulty of negotiating with the medical category, which creates impasses for this, according to the respondents. Therefore, only the plan of the state of Mato Grosso aggregates all the professionals of the same schooling in the same position. In the others, medical professionals are separated into specific positions or career plans. There is, also, the case of Alagoas, which manage nine different plans for professionals working in the UHS.

The guideline which presupposes the performance evaluation as a pedagogical and participatory process, covering, in an integrated way, all activities of the workers, whether individual, collective or institutional, has been accepted by all the plans studied, although this process is not yet in process in some places. Likewise, the premise of entering the career by public tender is also provided in the plans of the eight structures.

About shared management between workers, envisaged in the national guidelines, only Fesf stated that it did not correspond. As for the creation of joint careers commissions of managers and employees, with an unfolding for the negotiating tables, only the SHS of Alagoas and the MHS of Recife attend it; the SHS of Bahia is included in the general negotiating table of the state.

Career development, by promotion and progression by merit, determined by the guidelines, occurs in the SHS of Mato Grosso, MHS of Guarulhos and Recife, and in the SHS of Bahia. In the latter two, the service time is also used. In Alagoas, Tocantins and Fesf, service time and performance evaluation are used.

Lastly, the institutional program of qualification for valorization and professional development is not foreseen in the MHS plans of Goiânia and Fesf-BA.

Satisfaction of the workers about the CPPS

During the interviews, the satisfaction of the workers about the CPPS was also measured, in the perception of the managers, through a scale of the Likert type, with four grades, as follows: grade 1 - dissatisfied; grade 2 - little satisfied; grade 3 - satisfied; and grade 4 - very satisfied.

The answers obtained indicate that, in general, the professionals are satisfied (average=3) with the plans implemented. The respondents said that the greatest dissatisfaction is perceived in the medical category, mainly because they consider the salaries low.

The main claims of the workers are: regulation of processes foreseen in the plan, such as performance evaluation; extinction of social organizations; better working conditions and infrastructure; 30 hours for the nursing category; and implementation of permanent education processes.

Regarding the scarcity of health professionals, most of the managers stated that it is basically related to physicians, both for Primary Care (PC) and other levels of care. In reference of other professionals, the respondents reported the existence of an offer that exceeds their incorporation by the labor market.

As far as professional rotation is concerned, managers could not affirm that it decreased after the implementation of the CPPS, which constitute as recent events, and there is no, yet, enough data to support the evaluation of this indicator.

Discussion

The career is an organizational and comprehensive system of the trajectory of the work activities of the people; it has a social and administrative function that guides the mobility in the work market and the psychosocial function of giving meaning and motivation to the activities performed by the workers. The work career arose, in the world, at the beginning of the twentieth century, with the objective of organizing the trajectory of the employees' work life, to be traversed through positions and functions to be performed over time (ARONI, 2011ARONI, F. Carreira: visão acadêmica e práticas do mercado de trabalho relatadas pela publicação Guia Você S/A Exame 'As melhores empresas para você trabalhar'. 2011. 130 f. Dissertação (Mestrado em Psicologia) - Universidade de São Paulo, São Paulo, 2011.).

In Brazil, the traditional career gained an emphasis in the 1970s, in a context of repression of trade unions by the military dictatorship. Furthermore, investments in the industrial sector attracted low-quality manpower, that was trained only to perform the function, and the value of the employee was basically related to his working time. The 1980s were marked by strikes by the unions, in view of the economic stagnation and the consequent reduction of jobs and mass dismissal that devastated the Country (ARONI, 2011ARONI, F. Carreira: visão acadêmica e práticas do mercado de trabalho relatadas pela publicação Guia Você S/A Exame 'As melhores empresas para você trabalhar'. 2011. 130 f. Dissertação (Mestrado em Psicologia) - Universidade de São Paulo, São Paulo, 2011.).

In the last decades, the work market has been reconfigured, mainly due to the profound changes promoted by the technologization and the automation, that influence the work relations; and the reduction of stable jobs and the diversification of employment relationships, which, consequently, reorganize career structures and conceptions (BLANCH, 2003; SENNETT, 1998). The skills and abilities are valued, and there is a concentration of workstation with hiring through the Consolidation of Labor Laws (CLT) (CAMPOS, 2006CAMPOS, K. C. L. Construção de uma escala de empregabilidade: competências e habilidades pessoais, escolares e organizacionais. 2006. 172 f. Tese (Doutorado em Psicologia) - Universidade de São Paulo, São Paulo, 2006.; ARONI, 2011ARONI, F. Carreira: visão acadêmica e práticas do mercado de trabalho relatadas pela publicação Guia Você S/A Exame 'As melhores empresas para você trabalhar'. 2011. 130 f. Dissertação (Mestrado em Psicologia) - Universidade de São Paulo, São Paulo, 2011.).

Notwithstanding the devaluation of the public career ideology as a dream for every worker, the demands of public workers are still in force, especially those located in priority areas of the states - health, education and security -, for careers that allow the valuation of salary and working time, and that guarantee short-term benefits, such as additional and better working conditions.

Regarding health, since the implementation of the UHS, in 1990, it was already proposed to create careers for the professionals of the system, and it is, also, a requirement for the receipt of resources from the Union the implementation of a drafting committee of CPPS, by the municipalities (BRAZIL, 1990______. 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: <http://www.planalto.gov.br/ccivil_03/leis/L8080.htm>. Acesso em: 3 mar. 2017.
http://www.planalto.gov.br/ccivil_03/lei... ).

The final report of the II National Conference on Human Resources, performed in 1993, stated that professional development opportunities were limited, wages degrading, and career plans were non-existent. Such scenario would lead to the demotivation of the workers and the ethical and social decomposition with the health system (BRAZIL, 1993______. Ministério da Saúde. Coordenação-Geral de Desenvolvimento de Recursos Humanos para o SUS. II Conferência Nacional de Recursos Humanos para a Saúde: Relatório Final. Brasília, DF: Ministério da Saúde , 1993. (Cadernos RH Saúde; v. 1, n. 1).).

After more than 20 years of the aforementioned document, the scenario reported is no longer the same, but some problems still persist, such as: shortage of qualified professionals in work management; diversified modalities of occupational contracts; absence of adequate career plans, in much of the structures, or dissatisfaction of the workers with the existing plan; insufficient remuneration; difficulty in fixing professionals; limitation of the expansion of the personnel structure imposed by the Fiscal Responsibility Law; absence of public tenders; lack of qualification of the professionals; and lack of permanent education programs (BRAZIL, 2004BRASIL. Conselho Nacional dos Secretários de Saúde. Estruturação da Área de Recursos Humanos nas Secretarias de Saúde dos Estados e do Distrito Federal. Brasília, DF: Conass, 2004. (Conass Documenta; v. 1). Disponível em: <http://bvsms.saude.gov.br/bvs/publicacoes/documenta1.pdf>. Acesso em: 3 mar. 2017.
http://bvsms.saude.gov.br/bvs/publicacoe... ; PIERANTONI ., 2008PIERANTONI, C. R. et al. Gestão do trabalho e da educação em saúde: recursos humanos em duas décadas do SUS. Physis, Rio de Janeiro, v. 18, n. 4, p. 685-704, 2008., PIERANTONI; GARCIA, 2011PIERANTONI C. R.; GARCIA, A. C. Human resources for health and decentralization policy in the Brazilian health system. Human Resources for Health, London, v. 9, n. 12, 2011.; MAGNAGO; PIERANTONI, 2014MAGNAGO, C.; PIERANTONI, C. R. A percepção dos gestores dos municípios de Duque de Caxias e Rio de Janeiro quanto à rotatividade de profissionais na Estratégia Saúde da Família. Revista Cereus, Gurupi, v. 6, n. 1, p. 3-18, jan./abr. 2014.; NEY; RODRIGUES, 2012NEY, M. S.; RODRIGUES, P. H. A. Fatores críticos para fixação do médico na Estratégia Saúde da Família. Physis, Rio de Janeiro, v. 22, n. 4, p: 1293-311, 2012.).

It cannot be denied, however, that the Ministry of Health, through SGTES, has been making efforts to improve all aspects of the work management, and improvements are noticed when an evolution over time is evaluated. In reference to the CPPS, for example, a survey performed in 2008 found that 47,8% of SHS and MHS did not have any established model; 28,9% had a general plan for all workers; and 20,2% had CPPS specific to the health sector (PIERANTONI; GARCIA, 2011PIERANTONI C. R.; GARCIA, A. C. Human resources for health and decentralization policy in the Brazilian health system. Human Resources for Health, London, v. 9, n. 12, 2011.). In 2012, the percentage of those who indicated the lack of plans decreased to 29,1%; general CPPS were pointed out by 36,6%; and the percentage of respondents who indicated specific plans for the health sector increased to 28,7% (OBSERVARH-IMS/UERJ, 2014OBSERVATÓRIO DE RECURSOS HUMANOS EM SAÚDE (OBSERVARH-IMS/UERJ). Estação de Trabalho Instituto de Medicina Social da Universidade do Estado do Rio de Janeiro. Avaliação de Políticas e Programas Nacionais da Gestão do Trabalho e da Educação em Saúde no SUS. Rio de Janeiro: ObservaRH-IMS; UERJ, 2014. Disponível em: <http://www.obsnetims.org.br/uploaded/11_5_2015__0_Sumario_Executivo_Avaliacao_de_Politicas_e_Programas_Nacionais.pdf>. Acesso em: 3 mar. 2017.
http://www.obsnetims.org.br/uploaded/11_... ).

Nevertheless, the existence of a plan does not mean that all the processes foreseen in the legislation are, in fact, fulfilled, in the case of performance evaluation, which presents difficulties for its materialization, so that it is no longer just a bureaucratic act. A study performed by Seidl (2014)SEIDL, H. et al. Gestão do trabalho na Atenção Básica em Saúde: uma análise a partir da perspectiva das equipes participantes do PMAQ-AB. Saúde em Debate, Rio de Janeiro, v. 38, n. esp. p. 94-108, out. 2014. evidenced weakness in the incorporation of the performance evaluation in the career plans, especially in municipalities of smaller population size.

The improvement of the work management practices in health services is a major challenge. The performance evaluation is one of the focus of attention of the management process, and its purpose is to identify the level of professional training/qualification, as well as the potential of the workers in relation to the organizational objectives.

As a tool to help the decision-making process, the performance evaluation is considered as a data collection tool, which makes it possible to characterize the conditions that hinder or prevent the full and adequate exploitation of the workers of the organization. However, at the same time that the theme gains space for discussion in the public sector, it provokes controversy between managers and workers, mainly because the evaluation still raises, in the worker, an imaginary to reprimand, to punish. On the other hand, also, the performance evaluation processes conducted by most organizations still bring, in it, bureaucratic, merely technical and punctual connotations, that do not result in improvement of the processes of practices (PIERANTONI; GARCIA, 2011PIERANTONI C. R.; GARCIA, A. C. Human resources for health and decentralization policy in the Brazilian health system. Human Resources for Health, London, v. 9, n. 12, 2011.).

In this context of understanding that the performance evaluation is an important management tool, the structures studied by this research already bet on these processes, in order to try to meet the requirements of the services and health professionals, even if they are under development.

It should be borne in mind that the implementation of a CPPS does not only mean earnings in terms of remuneration. It can be a powerful tool for improving working conditions, professional training and, more than that, recognition of the worker.

It is known, however, that the implementation of a career plan, especially about the public sector, is a process that usually requires, generally, a long negotiation between the actors involved, especially the workers, who will enjoy the benefits, and for the state representatives, who must suggest and/or approve a proposal to raise the financial impact of a CPPS to the public coffers.

The participation of the worker is, first of all, essential for the achievement of the national health system. By stimulating this participation in the construction of a democratic public system, the commitment to the proposals of the sanitary reform movement is ratified with the objective of implementing the UHS (BRAZIL, 2007______. Ministério da Saúde. Secretaria de Gestão Estratégica e Participativa. Saúde, trabalho e democracia: a participação dos trabalhadores de saúde nos conselhos. Brasília, DF: Ministério da Saúde , 2007. (Série D. Reuniões e Conferências); (Série Cadernos Metropolitanos). Disponível em: <http://bvsms.saude.gov.br/bvs/publicacoes/07_0146_M.pdf>. Acesso em: 3 mar. 2017.
http://bvsms.saude.gov.br/bvs/publicacoe... ).

Negotiation is a fundamental process, which requires the agreement of interests and priorities by the various subjects involved in the work context (SILVA, 2012SILVA, N. D. Sistema nacional de negociação permanente do SUS: um instrumento de gestão do trabalho na saúde. 2012. 141 f. Dissertação (Mestrado em Saúde Pública) - Escola Nacional de Saúde Pública Sergio Arouca, Fundação Oswaldo Cruz, Rio de Janeiro, 2012.; BRAGA, 2002BRAGA, D. G. Conflitos, eficiência e democracia na gestão púbica. Rio de Janeiro: Fiocruz, 2002.), and, in this sense, the interests of each professional category, although legitimate, as well as the public-private relationship, which introduces the outsourcing of services within the scope of the UHS and produces various contractual modalities of work, also end up excluding most workers from the scope of work management policies, and inhibit, especially, the achievements of the projects of public career in the UHS (PAIM, 2013PAIM, J. S. A constituição cidadã e os 25 anos do Sistema Único de Saúde (SUS). Cadernos de Saúde Pública, Rio de Janeiro, v. 29, n. 10, p. 1927-1953, 2013.).

In addition, the underfunding of health, which is a chronic problem, has been aggravated in recent years, implying significant spending cuts in the sector, especially in the scope of the work management, an area that is undervalued throughout the history of the UHS. This scenario points to negative perspectives, especially because of the political-economic crisis that Brazil is undergoing, which has been used as justification for proposals of constitutional modification subject to freezing of federal spending on health for the next decades (PAIM, 2013PAIM, J. S. A constituição cidadã e os 25 anos do Sistema Único de Saúde (SUS). Cadernos de Saúde Pública, Rio de Janeiro, v. 29, n. 10, p. 1927-1953, 2013.; VIERIA, 2016).

Conclusions

The analysis of the data collected, whether through the documents referring to the plans, or through the speeches of the managers interviewed, pointed out different and diverse improvements in the scope of the management, emerging, mostly, after the implementation of a career plan. They also presented, still, challenges that deserve to be studied and worked harder, since they are fundamental for the development of the area of the work management and health education, for the professional fixation and valorization and, consequently, for the consolidation and improvement of the health services offered by the public national system.

Among the main challenges that are presented, the necessary health system planning and goal setting can be mentioned; the regulation of the process of performance evaluation and articulation with the policy of permanent education, according to the agreed goals; the valorization of the teamwork as an important indicator of professional performance; and the insertion of all professionals working in health, including administrative and health agents.

Thus, the process of implantation of a career plan should not be understood as a neutral piece, that is, prone to be justified by administrative rationality. It will always have, also, a political, economic, social and cultural character.

Undoubtedly, far from the depletion of the theme, new approaches are necessary to unveil and map the different experiences in vogue, in Brazil and in countries with universal health systems, by questioning, especially, the role of the state in regulating professions and health work, whose interfaces burden on work management.

References

Publication Dates

History