Managing the Basic Health Unit in tuberculosis control: a field of challenges

Abstracts

Neste estudo analisamos a gerência das Unidades Básicas de Saúde no controle da Tuberculose em um município do interior de São Paulo. Participaram do estudo 14 gerentes; a coleta dos dados foi realizada por meio de um questionário fechado e uma questão aberta, e também por meio de entrevista com consentimento livre e esclarecido. Para o tratamento dos dados, utilizamos o Programa Statística 8.0 da Statsoft, e para os dados qualitativos, utilizamos a técnica de análise de conteúdo, modalidade temática. Fica explícita uma gerência técnico-burocrática, com debilidades nas dimensões do planejamento e organização das atividades dos serviços de saúde. Assim, os gerentes desta investigação necessitam incorporar aspectos do planejamento e organização como forma de viabilizar a política de controle da TB.

Tuberculose; Gerência; Planejamento em saúde; Sistemas de Saúde

ORIGINAL ARTICLE

Managing the basic health unit in tuberculosis control: a field of challenges

El gerenciamiento de las unidades básicas de salud en el control de la tuberculosis: un campo de desafíos

Simone Teresinha Protti^I; Laís Mara Caetano da Silva^II; Pedro Fredemir Palha^III; Tereza Cristina Scatena Villa^IV; Antonio Ruffino-Neto^V; Jordana de Almeida Nogueira^VI; Lenilde Duarte de Sá^VII

^INurse. Doctoral student at Ribeirão Preto College of Nursing, University of São Paulo. Ribeirão Preto, SP, Brazil. [e-mail]

^IINursing undergraduate at Ribeirão Preto College of Nursing, University of São Paulo. Ribeirão Preto, SP, Brazil. [e-mail]

^IIIFree-Lecturer at Ribeirão Preto College of Nursing, University of São Paulo. Ribeirão Preto, SP, Brazil. [e-mail]

^IVFull Professor at Ribeirão Preto College of Nursing, University of São Paulo. Ribeirão Preto, SP, Brazil. [e-mail]

^VFull Professor at Faculdade de Medicina de Ribeirão Preto, University of São Paulo. Ribeirão Preto, SP, Brazil. [e-mail]

^VIPhD. Professor at Federal University of Paraíba. João Pessoa, PB, Brazil. [e-mail]. Professor at Federal University of Paraíba. João Pessoa, PB, Brazil. [e-mail]

^{Correspondence addressed to}

ABSTRACT

In this study we analyzed the management of Basic Health Units in terms of Tuberculosis (TB) control in a city in the interior of São Paulo state. Fourteen managers participated in the study. A closed questionnaire was administered and an open question was also applied. The interview was carried out after obtaining free and informed consent. Data analysis was performed using the Statsoft software Statística 8.0 and thematic content analysis was used for the qualitative data. It was found there is a clear technical-bureaucratic management, deficient in the activity planning and organization dimensions at the BHU. Hence, health care managers in this study should include management aspects of planning and organization as ways to make TB control feasible.

Key Words: Tuberculosis. Management. Health planning. Health Systems.

RESUMEN

En este estudio analizamos el gerenciamiento de las Unidades Básicas de Salud en el control de la Tuberculosis en un municipio del interior de San Pablo, Brasil. Participaron del estudio 14 gerentes. La recolección de datos fue realizada a través de un cuestionario cerrado y una pregunta abierta, más entrevista con consentimiento libre y esclarecido. Para el tratamiento de los datos, utilizamos el programa Statistica 8.0 de la compañía Starsoft; y para los datos cualitativos, se usó la técnica de análisis de contenidos, modalidad temática. Quedó evidenciada una gerencia técnico-burocrática, con debilidad en las dimensiones de planeamiento y organización de las actividades de los servicios de salud. De tal modo, los gerentes que participaron de esta investigación necesitan incorporar aspectos de planeamiento y organización como modo de viabilizar la política de control de la TB.

Descriptores: Tuberculosis. Gerencia. Planificación en salud. Sistemas de Salud.

INTRODUCTION

Tuberculosis (TB) is a calamity that worries health authorities over the world. In 1993, the World Health Organization (WHO) declared TB as a state of urgency and created the STOP TB program, which is formed by institutions of high scientific level and/or economic power, such as the WHO, the World Bank, Centers for Disease Control (CDC)-Atlanta, International Union Against Tuberculosis and Lung Disease (IUATLD), Royal Netherlands Tuberculosis Association (RNTA) and American Thoracic Association (ATA)⁽¹⁾.

Nowadays, TB leads as the cause of death by infectious diseases among adults, despite the technological advancements and the available health actions for its control and even eradication⁽²⁾. According to the WHO, one third of the global population is infected by TB. There are two billion infected individuals, eight million of which will develop the disease, and 1.8 million will eventually die⁽³⁾.

In the ranking of countries with the highest TB rates, 22 should receive special attention for being responsible for 80% of the estimated TB cases in the world. Brazil ranks 16^th among those countries⁽⁴⁾.

Municipalities should develop TB control programs based on the norm and orientations of the current National Tuberculosis Control Plan (PNCT, acronym for Plano Nacional de Controle da Tuberculose). To do that, it should be emphasized there is a need to make adjustments regarding the local diversities, especially in terms of the Supervised Treatment (ST)⁽³⁾.

In the year 2000, the Health Ministry implemented the "Strategic Plan for Tuberculosis Control in Brazil 2001-2005", which includes partnerships with primary care services, mainly with the Community Health Agents Program (PACS, acronym for Programa de Agentes Comunitários de Saúde) and Family Health Program (PSF, acronym for Programa de Saúde da Família), aiming at the expansion of TB control actions with the purpose to obtain greater detection and cure of disease cases⁽³⁾.

The execution of TB control actions was transferred to subnational departments after the 1980's, by establishing agreements⁽⁵⁾; which made the manager an essential factor for the development of TB control.

OBJECTIVE

To analyze the view of Basic Health Unit managers regarding TB control actions in Primary Health Care (PHC).

LITERATURE REVIEW

The decentralization of health actions triggered by the national public health system (referred to as SUS - Sistema Único de Saúde, which may be translated as Unique Health System), leads to a reflection of the process of health being administrated at the municipal level, which is part of the administrative reform in Brazil. For the municipalities, those innovations are the possibility to, starting in the health area, reorganize and restructure the local management having as a guideline a democratic and participative management that is technically competent and efficient⁽⁶⁾.

In this sense, special attention should be given to managerial technology, because it is what permits thinking and acting in health, i.e., to project the implementation of a health system that follows a hierarchy, is regionalized and counts with effective social participation. It should be emphasized that the municipalization of health contributes to strengthening the political-managerial autonomy of municipalities, thus increasing their technical-operational capacity for planning, programming, and the administration and implementation control of actions aimed at solving health problems in specific territories⁽⁶⁾. The thought of an efficient and competent management from an administrative point of view makes us believe that the referred propositions are essential for the development of adequate actions for TB control. Those actions cannot be developed individually, rather they should always take the collective character into consideration, working as a team with a management that has complete knowledge about the location, i.e., one that knows the health needs of that population. Furthermore, a management that is participative in the administration council when making decisions.

Management work in the production of health services is an important instrument when making public policies effective, as it is both a conditioner of and conditioned by the form by which the health service production is organized as well as the current technical-care model⁽⁶⁾.

To invest in the improvement of Basic Health Units and Reference Units management contributes to provide PHC with more quality, which has a direct effect on the health care to the population and community⁽⁷⁾.

When we chose to develop, in the present study, a discussion on the management theme, our perspective was of understanding it as an instrument for health work that would contribute with the transformation of health care practice regarding the improvement of TB care, and, therefore, aiming at a user-centered model that would result in changes and be committed with the health of the population.

Thinking about management as a potential for transformation, it may be perceived as an area for implementation, in which the health workers team may participate more, i.e., rethink about their form of production and reproduction regarding the management of local health services⁽⁸⁾.

It should be pointed out that the discussions that took place in the health area regarding the management theme and the group of interventions from several social groups involved that were interested in this theme highlight the need to make changes in how management work is developed, at every level of health organizations. The authors also point out that many debates that have management as the main issue make references to the macro-structural dimensions of health management work, and only a few highlight the intentions of making changes based on the acquisition of technical and operational capacity for acting over micro-political aspects of this working process⁽⁹⁾.

The main focus of the present study are micro-policies, as it discusses on the participation of the Basic Health Unit management in the administration of TB care in a municipality in the state of São Paulo.

Efficiency and efficacy are categories used and accepted by every school of administration to measure management performance. Efficiency and efficacy enter the debate on public health including the technical and rational elements, as well as the politics and power domains and its consequences⁽⁹⁾.

In this context, the categories of efficiency and efficacy were reconsidered having as variables the classical functions of administration, such as: the planning, the organization, the direction and the control, thus, adapted to the local health area. Efficacy, from the perspective of the health area, is defined as the ability of managers to achieve results in the activities of planning, organization, direction and control, without disregarding the greater purpose that is to solve the health problems of the clients⁽¹⁰⁾.

The planning, organization, direction and control compose the managerial process in terms of the activities having a dynamic interaction, being interrelated and interdependent, and take place in routine activities simultaneously or at different times⁽¹¹⁾.

The authors also indicate that the planning is the ability to foresee the future based on the clear comprehension of the limits and possibilities of the reality and, in the specific case of the health area, the immediate and mediate needs of the population under the responsibility of a particular health unit. The organization comprehends the capability of relating activities, decisions and people to achieve results, associated to leadership, and defines work strategies. The direction is the ability of decision-making and interrelationship, not only at a work unit, but at all hierarchical levels of the organization. Control presupposes the manager's ability to use and adapt systems of information in order to evaluate the work he is given, besides showing responsibility and compliance with the institutional results and commitments. Planning and control are related to the organizational efficacy, whereas organization and direction refer to efficiency⁽⁹⁾.

This study considers the hierarchical classification of the four managerial levels: a) superior managers: global administration and formulation of policies; b) technical managers: coordination and operationalization of policies and programs; c) infra-structure managers: responsible for the supply of strategic input for the operation of the organization; d) care managers: care actually takes place, the main purpose of the organization⁽⁹⁾.

Based on the description of the study object, the authors proposed to focus on the figure of the managers of the Basic Health Units from the studied municipality. Therefore, the subjects of this study were classified as care managers and the management dimensions of the health planning and organization were considered as analysis axis.

METHOD

Study of quanti-qualitative nature that used a closed questionnaire, aimed at the BHU managers. A guiding question was included at the end of the instrument: "Which difficulties do you, as a BHU manager, face in the every day routine to develop the actions of TB control?" The scenario was a municipality in the interior of the state of São Paulo, with population over 550,000 inhabitants. The study subjects were 14 BHU managers. The data from the structured instrument (questionnaires) were analyzed through the program Statistica 8.0 of Statsoft, and tables of simple frequency were made in order to obtain a general overview of the study. For the qualitative approach stage, the authors used a semi-structured interview and the technique of Thematic Content Analysis, which aims to go beyond the manifested meanings. Therefore, the content analysis proposes to relate the semantic structures (signifier) to the sociological structures (signification) of the statements and to articulate the described text with the factors that determine its characteristics: psychosocial variables, context and message production process⁽¹³⁾.

RESULTS

This discussion was built based on the statements of the managers, in which the following aspects were highlighted: TB in the sanitary scenario of the municipality, the planning in health and the actions to control the disease, the participation in the discussion and definition of actions for TB control, and the technical-bureaucratic aid of the management in the TB control.

Most of the managers, 81.3%, consider TB as a priority disease. The TB decentralization results from a legal-juridical set that has been consolidated since the end of the 1980's, which makes the municipality the management of health actions^(5-6). Nevertheless, the managerial decentralization finds obstacles in its operationalization, such as: the lack of technical ability and the low fiscal competence of the municipalities to take over such responsibilities, among others^(1,7). The manager presents the problem:

I think the vertical model of some services makes it difficult to install bonds and to organize the health services. I believe the basic care provides another character, aimed at other ways to build the work (EG1).

The manager explains the limits of traditional programs in the quality of health actions; thus, when other spheres elaborate the planning of the programs, it does not always agree with the local reality, compromising the technical-scientific quality of the actions. The field of planning in health demands constant changes and, therefore, the organization, management and evaluation of the scenario must be revisited by the local manager⁽⁸⁾. It is important to highlight that the goals defined by the PCT (Tuberculosis Control Program) line up with the critics made towards the normatization of the planning in health. In this context, case detection finds limits in its incorporation in a continuous and frequent way in PHC⁽¹¹⁾. The statements indicate aspects that concern the focus of the actions.

When I was a manager in Jardim Aeroporto, we emphasized the TB week, later, the posters were displayed in the Health Units, and if a patient had any symptom, he could read the posters when he arrived at the unit and look for a nurse to talk about it (TB symptoms) (EG2).

More emphasis is given to Dengue, for instance, and other diseases, like TB and HIV, are left aside (EG6).

The worst problem is that everyone gets involved in TB campaigns, the staff, even the cleaner, but everyone forgets later. If you look at the graphs you can see that the highest collections are on campaigns, and the lowest are out of campaigns. This is very complicated (EG10).

The speeches show TB in PHC in a restrictive way, as 81.3% of the subjects consider it a priority in the sanitary scenario of the municipality. This accuracy and value of the disease focus reveals the peculiarities of the decentralization discussed in other studies⁽¹¹⁾. These characteristics lead to the permanence of the culture of the campaign movement in the organization of local systems, with fragmented care in the health programs, distortions and low impact in the health production⁽¹²⁾; specially in the case of TB, which demands a longitudinal monitoring. Regarding the TB, the responsibilities for the control of actions for this pathology are placed in the scope of the Basic Care as of the edition of the Operational Health Care Norms (NOAS, acronym for Normas Operacionais de Assistência à Saúde) 2001 and 2002⁽¹¹⁾.

In face of this context, the management of the Basic Health Units starts to incorporate several actions under their responsibility, both in the managerial and in the care plan. These two dimensions allow to elaborate plans and strategies that make viable combined actions of the health teams from the Basic Health Unit (BHU) and the Municipal Health Department (MHD).

Observe the statements below:

Another fact is that the patients do not take responsibility for the care to their own health, we cannot be after them all the time. Most of the population here is hard-working, I believe our working hours may be limiting for them (EG14).

But I think there is still a lack of clarification for health professionals, because the users sometimes come here with a symptom and they (professionals) do not think it can be TB (EG5).

The managerial dimension becomes an important ally in the organization of TB actions, since a systematized and integral care for each patient is needed, aimed at the singularity and resolvability of the needs of these patients and their families, whenever possible.

The identification of respiratory symptoms is not an easy task; the execution of this activity requires its understanding as a complex action, since it is not enough to ask the individual whether he has been presenting cough. The health professional must be able to trigger all stages that involve that process, considering the anthropological aspects that permeate this action. This task implies a broad approach of the patient and goes through the health-disease process⁽¹¹⁾.

I am going to ask the agents and the nurses for help (to answer the questionnaire), because they have more contact with this reality (TB) than I do (EG13).

I am only the manager of the basic unit and I do not have knowledge about aspects related to the management of resources aimed at the TB control program. You should look for people who work with TB. We do not even have many cases here, and I do not have to know whether there are resources for that. My competence is to manage the basic unit where I am (EG11).

These statements lead to the idea that the subject takes the management performance from the technical-bureaucratic point of view, against the idea of the Strategic Planning⁽¹⁰⁾. This aspect has already been the analysis field of other authors⁽¹⁰⁾; showing the managers' lack of knowledge about the health problems of their territory, and requiring a greater participative involvement to rethink the production and reproduction of the management aspects^(9,11).

Managers have a fundamental role to change the way of thinking about the provided care and the intervention strategies adopted in the health systems. Therefore, managers must be sensitive towards the need for management strategies to face chronic conditions, such as TB⁽⁴⁾.

The BHU manager must plan the health actions of his coverage area according to the needs of its population. Some authors consider that the area of planning and management in health has a potential for changes and innovations in the process of organization, management and evaluation, which must be frequently revisited by the manager⁽¹⁰⁾.

Regarding the participation of the managers in the discussion and definition of actions for the control of TB in the municipality, 31.3% of the managers stated they sometimes participate, whereas 18.8% revealed they almost never participate. This indicates that over 50% of the managers have little participation, including that there are some who do not know such systematic.

This situation seems to agree with the questions previously raised at the discussion regarding the lack of compliance with the actions of case detection, indicating little political commitment to the maintenance and continuation of these actions in PHC⁽¹¹⁾. The speech of the manager refers to the intersectorial discussion.

The same thing that happened in Campinas should start here (in the municipality), because the opening of industries brings more money and tries to improve the life condition of the population, since TB is a disease of social character that affects the less favored layers of the population (EG6).

The manager proposes new care technologies and the organization of the health system, bringing the shared responsibilization as one of the practices of the management and the TB care teams⁽¹¹⁾; given its social character that demands the organization of the work, social participation and the incorporation of non-governmental organizations (NGOs)⁽¹³⁾. These questions agree with the policy of decentralization of TB actions, as well as with the managerial work in the formulation, political decision, innovative and proactive attitude, improvement of the access, compliance with the treatment and bond to health professionals⁽¹⁴⁾.

This context seems to reveal the importance of the search for institutional partnerships to support and control TB actions. According to a study⁽¹⁴⁾; the National Tuberculosis Control Plan (PNCT, acronym for Plano Nacional de Controle da Tuberculose) of 1998 had already seen the need for social participation and the incorporation of non-governmental organizations (NGOs) in the disease control.

In this perspective, it is understood that by incorporating TB actions in PHC, the Health Ministry aimed to approach and redirect the care model, promoting benefits in terms of improvement of the access, compliance with the treatment and bond to health professionals. Therefore, considering diseases with chronic character, such as TB, implies to consider the need for the incorporation of new technologies in the organization of the health care, through partnerships with other social sectors, as one of the elements that must follow the practices of the management and the teams in the stage of planning in health⁽¹¹⁾.

The study showed that 52.6% of the managers stated to be in the management position for up to five years, 26.3%, from five to ten years and, 5.3%, for fifteen years or more. This scenario indicates the accumulation of experience in this function. Therefore, the little participation in these discussions does not seem to have a relation with the work period in this position. When TB is recognized as a neglected disease⁽¹⁾; we come across a complex context in which PHC professionals have difficulties to diagnose TB and the health services lack the appropriate managerial organization to provide care to the patients⁽⁵⁾.

Health professionals are still very unprepared towards TB. There cases in which a patient that comes to the unit with complaints, like cough and mucus with blood, is seen by the general physician and only sent to the pulmonologist, so it takes a long time to be diagnosed (EG4).

We have few cases of TB here, just 01 that I recall, because they go to the Reference Center, they are monitored there, not here (EG5).

The reorganization of the care system, allied to the managerial performance, become fundamental conditions in the social production in health in TB. Studies involving managerial aspects have evidenced the lack of preparation in the municipality scope, the deficiency of its technical-managerial structure and the limits of its own decentralization as obstacles in the advancement of the TB control^(5,14-15).

The course of time between the first respiratory symptoms and the beginning of the treatment has a specific registration field on the TB research form (CVE-ESP), however, the author verified that this information was only given in 70% of the new cases in the municipality. In this context, this information may not be recalled with accuracy by the patient; at the same time, its registration may be an object of study by the professional. From the care point of view, this fact may have different connotations: one resulting from the individual and social characteristics of the patient that lead him to look for the service only when he perceives to be sick, that is, with advanced symptoms; the other, from professionals, since the lack of records may imply inadequacy in the therapeutic process^(16-17).

The period of delay also depends on the organization of the health services, the first professional who approaches this individual, the access to the first medical appointment, the delay in the disease suspicion, the availability of material for the request of exams (mucus container, printings, refrigerator to store the material), the availability of other diagnostic exams (radiologic), the time between the collection of material for exam and the arrival of the result, the transference and scheduling of the patient to the service that will perform the treatment ⁽¹⁶⁾.

The authors remind that this delay will depend on the patient's arrival at the service, in other words, the access to the home location, transportation condition until the institution of the treatment, and it will also depend on the bond to the health professionals.

The statement of this manager indicates some of these obstacles.

There was a user here who took 09 months to discover he had TB. He would complain about coughing, see the doctor, take syrup, and then he would come again, and it was only at the end of several months that the pulmonologist diagnosed TB (EG4).

It is possible that we do not diagnose some cases, but when there is the diagnosis we follow up, we ask for the family to come to the unit (EG5).

These aspects show that there is a depersonalization of the health services towards the care to TB. The user is punished and needs to wander through the services until he obtains the diagnosis of the disease, which does not always happen in PHC. This subjection and impersonality in the care interfere in the stigma of the disease, and makes it only part of the health statistics^(17-18) These are some of the elements that broaden and present the problem in discussions about the managerial work in the TB control.

FINAL CONSIDERATION

The indifference points to the lack of knowledge of the managers towards the PCT, revealing their alienation regarding the TB problem in their coverage area. The political commitment of the managers is compromised, since they are responsible for the planning, organization, direction and control of the programs. This may be related to the fact that the managers do not see themselves as managers, responsible for making decisions at their unit as well as for the incorporation and for making the TB actions feasible in PHC.

REFERENCES

Received: 11/25/2008

Approved: 09/23/2009

* Extracted from the thesis "A visão dos gerentes das Unidades Básicas de Saúde sobre a Tuberculose na Agenda Municipal, em um município do Estado de São Paulo", Ribeirão Preto College of Nursing, University of São Paulo, 2008

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Correspondence addressed to:

Simone Teresinha Protti

Av. Bandeirantes, 3900 - Campus Universitário

CEP 14040-902 - Ribeirão Preto, SP, Brazil

Publication Dates

• Publication in this collection
  07 Oct 2010
• Date of issue
  Sept 2010

History

• Received
  25 Nov 2008
• Accepted
  23 Sept 2009