The process of implementation of emergency care units in Brazil

O'Dwyer, Gisele; Konder, Mariana Teixeira; Reciputti, Luciano Pereira; Lopes, Mônica Guimarães Macau; Agostinho, Danielle Fernandes; Alves, Gabriel Farias

doi:10.11606/S1518-8787.2017051000072

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Sumário

Original Articles • Rev. Saúde Pública 51 • 2017 • https://doi.org/10.11606/S1518-8787.2017051000072 copy

The process of implementation of emergency care units in Brazil

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

OBJECTIVE

To analyze the process of implementation of emergency care units in Brazil.

METHODS

We have carried out a documentary analysis, with interviews with twenty-four state urgency coordinators and a panel of experts. We have analyzed issues related to policy background and trajectory, players involved in the implementation, expansion process, advances, limits, and implementation difficulties, and state coordination capacity. We have used the theoretical framework of the analysis of the strategic conduct of the Giddens theory of structuration.

RESULTS

Emergency care units have been implemented after 2007, initially in the Southeast region, and 446 emergency care units were present in all Brazilian regions in 2016. Currently, 620 emergency care units are under construction, which indicates expectation of expansion. Federal funding was a strong driver for the implementation. The states have planned their emergency care units, but the existence of direct negotiation between municipalities and the Union has contributed with the significant number of emergency care units that have been built but that do not work. In relation to the urgency network, there is tension with the hospital because of the lack of beds in the country, which generates hospitalizations in the emergency care unit. The management of emergency care units is predominantly municipal, and most of the emergency care units are located outside the capitals and classified as Size III. The main challenges identified were: under-funding and difficulty in recruiting physicians.

CONCLUSIONS

The emergency care unit has the merit of having technological resources and being architecturally differentiated, but it will only succeed within an urgency network. Federal induction has generated contradictory responses, since not all states consider the emergency care unit a priority. The strengthening of the state management has been identified as a challenge for the implementation of the urgency network.

DESCRIPTORS
Emergency Medical Services; Manpower; Health Manager; Health Services Administration; Resources Management; Health Management; Health Policy

Federative units		2011		Existing UPA	2016	UPA built but not working
Federative units		Existing UPA	UPA under construction	Existing UPA	UPA under construction	UPA built but not working
North Region
	Acre	2	1	2	5	0
	Amapá	0	3	1	3	0
	Amazonas	0	9	1	4	0
	Pará^* * States with an expressive number of UPA not working, probably because some are newly built and still have no working conditions from the lack of professionals and materials.	1	20	11	40	13
	Rondônia	0	3	2	7	2
	Roraima	0	1	0	1	0
	Tocantins^* * States with an expressive number of UPA not working, probably because some are newly built and still have no working conditions from the lack of professionals and materials.	2	4	6	7	4
	Total	5	41	23	67	19
Northeast Region
	Alagoas	0	6	8	8	2
	Bahia	1	32	29	52	12
	Ceará	0	19	26	26	9
	Maranhão	1	7	11	17	3
	Paraíba	1	6	10	18	2
	Pernambuco	14	6	18	28	7
	Piauí^* * States with an expressive number of UPA not working, probably because some are newly built and still have no working conditions from the lack of professionals and materials.	0	3	2	12	3
	Rio Grande do Norte	3	6	6	11	2
	Sergipe	0	0	4	7	0
	Total	20	85	114	179	40
Midwest Region
	Federal District	1	8	6	4	0
	Goiás^* * States with an expressive number of UPA not working, probably because some are newly built and still have no working conditions from the lack of professionals and materials.	1	17	14	34	12
	Mato Grosso^* * States with an expressive number of UPA not working, probably because some are newly built and still have no working conditions from the lack of professionals and materials.	0	8	4	23	2
	Mato Grosso do Sul	0	4	7	7	2
	Total	2	37	31	68	16
Southeast Region
	Espírito Santo	1	5	4	8	0
	Minas Gerais	8	43	45	47	10
	Rio de Janeiro	43	16	70	12	2
	São Paulo	13	95	99	145	19
	Total	65	159	218	212	31
South Region
	Paraná	9	22	34	30	6
	Santa Catarina^* * States with an expressive number of UPA not working, probably because some are newly built and still have no working conditions from the lack of professionals and materials.	2	12	10	21	6
	Rio Grande do Sul^* * States with an expressive number of UPA not working, probably because some are newly built and still have no working conditions from the lack of professionals and materials.	0	26	16	43	16
	Total	11	60	60	94	28
Total Brazil		101	381	446	620	134

Situation identified in the UPA	Evaluation of interviewees	Our analysis
To meet low and medium severity urgencies complementarily to primary care	The quantitative and qualitative insufficiency of the primary care produces this pattern of care.	The UPA has its function in the low severity care as it works 24 hours, complementing primary care. However, it should not be implanted to replace primary care.
"UPA meet outpatient clinic situations in most cases" (E5)
"Patients of the UPA should be in PC. Government should decide to invest in PC" (E22)	They indicate that the noninvestment in primary care has been replaced by UPA.
To be complementary to hospital emergency	The UPA were implemented to replace hospital emergency rooms and, in smaller municipalities, to replace inefficient hospitals.	The meeting of the low-risk demand in pre-hospital units may benefit the hospital emergency that should prioritize the more complex cases. However, that is not the purpose of the UPA.
"UPA are close to hospitals to replace the ER of the hospital" (E8)
To work as an inpatient unit	The interviewees are against the "hospitalization" in the UPA. However, they admit that some managers count the beds of the red room as hospital beds, including ICU.	The only role of the UPA in the care of the critical patient is his or her stabilization. The UPA is 24h because it is open uninterruptedly and not because it can tolerate the patient's stay for 24 hours awaiting beds.
"UPA should not work as a hospital of low resoluteness because of the lack of beds"(E9)
"Patient admitted to the UPA and UPA do not receive AIH" (E13)
"UPA do well: they meet the low complexity, refer to the average, stabilize the serious condition, but hospitalization is bad" (E14)

Category of the structuring theory		Scenario found	Statements of managers
Structuring types	Meaning - reflects an interpretive plan	UPA as a component that enables access versus UPA as a component isolated on the network	"It must give access, meet the low complexity, refer to the average, stabilize the serious condition" (E10 and E14)
	Meaning - reflects an interpretive plan		"A backset because it is isolated. It breaks the PC model" (E9)
	Legitimacy - compliance with standards	UPA as an integrated component in the network, according to ordinances	"I think the UPA is fundamental for the network" (E22)
	Legitimacy - compliance with standards		"Professionals understand the importance of meeting the urgency of low complexity, complementarily to PC" (E15)
	Domination - mobilization of allocative (material capacities) and authoritative resources (relation between persons)	Implementation of required units versus	"There is political articulation. The state government is requesting the UPA together with the municipality" (E11)
		Political implementation	"Policy goal of the Office of the President's Chief of Staff for 2013. It asks the MH to execute it without the state" (E12)
Agency - knowledge and action of institutional players	Action of the municipal player	Municipal managers using allocative and authoritative resources	"The municipal manager has nowhere to wash clothes, make food, and decides to put all this in the UPA, handling the financing. The manager is changed and the new one does not understand why the UPA is so big and expensive, a burden for the structure of the municipality" (E16)
			"Doctors left with the change of manager. We have thrombolytic and the new doctors don't know how to use it" (E5)
	Action of the state player	State managers carry out the urgency plan and define their management priorities and needs for the state	"State plan to open ICU beds in each health region. Consideration of the treasury" (E9)

Federative units		Total of UPA	Location		Size of UPA			Sphere of management
Federative units		Total of UPA	Capital	Countryside	I	II	III	Municipal	State
North Region
	Acre	2	2	0	1	0	1	0	2
	Amapá	1	1	0	1	0	0	0	1
	Amazonas	1	1	0	0	0	1	0	1
	Pará	11	1	10	2	5	4	11	0
	Rondônia	2	2	0	0	2	0	2	0
	Roraima	0	0	0	0	0	0	0	0
	Tocantins	6	3	3	1	5	0	6	0
	Total	23	10	13	5	12	6	19	4
Northeast Region
	Alagoas	8	1	7	3	3	2	1	7
	Bahia	29	8	21	14	6	9	26	3
	Ceará	26	9	17	10	8	8	3	23
	Maranhão	11	4	7	1	7	3	1	10
	Paraíba	10	2	8	6	3	1	6	4
	Pernambuco	18	5	13	3	1	14	3	15
	Piauí	2	1	1	1	0	1	1	1
	Rio Grande do Norte	6	2	4	2	3	1	5	1
	Sergipe	4	0	4	4	0	0	3	1
	Total	114	32	82	44	31	39	49	65
Midwest Region
	Federal District^* * Federal District: UPA in Brasília is classified as capital and state management to compute the sum.	6		6	0	0	6	6
	Goiás	14	2	12	4	5	5	14	0
	Mato Grosso	4	1	3	2	1	1	4	0
	Mato Grosso do Sul	7	4	3	2	2	3	7	0
	Total	31	13	18	8	8	15	25	6
Southeast Region
	Espírito Santo	4	0	4	0	3	1	4	0
	Minas Gerais	45	6	39	11	9	25	45	0
	Rio de Janeiro	70	32	38	1	10	59	38	32
	São Paulo	99	2	97	39	41	19	99	0
	Total	218	40	178	51	63	104	186	32
South Region
	Paraná	34	8	26	8	13	13	34	0
	Santa Catarina	10	2	8	6	1	3	10	0
	Rio Grande do Sul	16	1	15	7	5	4	13	3
	Total	60	11	49	21	19	20	57	3
Total Brazil		446	106	340	129	133	184	336	110

Category	Illustrative statements	Analytical synthesis
Implantation and expansion of emergency care units (UPA)	"The value that the ministry of health and the state will give … this cost is still very high for the municipality" (E13)	Federal underfunding
	"The state is not interested. I think the pre-hospital service it has is enough and one more component, the UPA, will not change much" (E9)	Rejection of the state
	"I see the UPA as an evolved model of the emergency care that had no resolutiveness. From physical space, team qualification, equipment, medication, the UPA model is more appropriate" (E7)	Acceptance of the state
Structural conditions for care	"Well structured, they improved the working conditions of professionals" (E5)	Good structural conditions
	"We have UPA that are much better than the urgency of the hospital" (E24)	Good structural conditions
	"Lack of pediatrician, serious problem" (E13)	Lack of medical professionals
The UPA and other components of the emergency network	"In the countryside, small municipalities have 100% of coverage of the FHS, but the doctors attends once, twice a week" (E6)	Difficulty in relation to primary care
	"The state wanted to have ICU beds in the UPA" (E5)	Lack of hospital beds
	"Mirror Hospital - metropolitan reference hospital with SH or philanthropic hospital that integrate each other to define pharmacy, bed rotation, etc." (E11)	Strategies to cope with difficulties in hospital management
Management of UPA and interaction between federated entities	"Regional UPA does not make sense. All municipalities have a small hospital that has to solve more than the UPA. The municipality ceases to invest in a service for it to invest in another regional hospital that does not have great resolutiveness. It would be different if it were a specialized regional hospital that would solve more than the municipality is capable" (E9)	Difficulty of agreement between municipalities
	"The municipality asked for an UPA in 2009, but gave up and returned the appeal. The state is resisting assuming it because the pre-hospital park it has is enough" (E6)	Difficulty of agreement between municipality and state

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[1] Correspondence: Gisele O'Dwyer Departamento de Administração e Planejamento em Saúde - ENSP Av. Leopoldo Bulhões, 1480 Sala 727 Manguinhos 21041-210 Rio de Janeiro, RJ, Brasil E-mail: odwyer@ensp.fiocruz.br