Innovation in the role of the Office of the Ombudsman of the Unified Health System ( SUS ) – reflections and potential benefits

This article seeks to reflect on the potential of innovative practices in the design and work of the government bodies that comprise the National System of Offices of the Ombudsman of the Unified Health System. It is divided into two parts, seeking to answer the following question: How to think of and implement innovative practices – which include sustainability – when the people are voicing their urgent demands and these are being heard by the public authorities? These grievances are all the more urgent as they involve the area of Health and can they be promptly discussed, attended and resolved? In the first part, the article discusses the polysemic concept of innovation, focusing on its application in the three spheres of public administration, and highlights the importance of its close correlation with the different notions of information and knowledge in a society such as the one we live in. In the second, it develops a task-force of ideas for the office of the ombudsman and based on this, a draft operational concept of innovation in the role of the office of the ombudsman, considering the context of high speed change and transformations and the complexity inherent to contemporary life and the need for resource management and expertise development in information management.


Introduction
In the history of human achievement, it can be seen that innovation has been a question of necessity, of adaptation, of inventiveness and, ultimately, one of survival.To innovate, in the sense of going further by inventing something new, by constructing that which has never been thought of before or executed, or to improve that which already exists, has meant and continues to mean using the attributes of creativity to confront and to resolve problems, from the most basic to the most complex.
Thought-provoking questions arise when we correlate the idea of "innovation" together with public management: What form will innovation take when related to public policies?How should we seek, implement and achieve innovation, involving public policies in terms of government responses to the needs and demands of the population, given that these express concrete issues that require immediate and effective solutions?How is it possible to think of and implement innovative practices -especially those that involve sustainability in their process of redevelopment -when the people are voicing their urgent demands and these are being heard by the public authorities; These grievances are all the more urgent when they involve the area of Health and can they be promptly discussed, attended and resolved?How can the Offices of the Ombudsman receive, process and deal effectively, efficiently and adequately with the concerns expressed by the citizens, about the problems they face when dealing with the Unified Health System (SUS), while at the same time considering the concept(s) of "innovation"?
This article aims to reflect on these issues, so as to explore the potential benefits of innovative practices in the concept and work of the offices that comprise the National System of Offices of the Ombudsman of the Unified Health System (SNO-SUS) 1 , the coordination of which is the responsibility of the Ombudsman-General's Office of the Strategic and Participative Management Department of the Brazilian Ministry of Health (DOGES/SGEP/MS).This system is currently being designed and proposes to implement, in the three spheres of government, a network of Offices of the Ombudsman capable of providing support for the health demands of society -referred to as grievances, systematizing and processing these in such a way as to subsidize public management in the formulation, implementation, execution and evaluation of policies 2 .
The text is structured in two parts: In the first part, the polysomic concept of innovation is dis-cussed, focusing on the way this is implemented in the field of public administration, and it highlights the importance of its close correlation with different notions of information and knowledge in a society such as the one we live in.In the second part, based on the rationale of the first, a task-force of ideas for the office of the ombudsman and based on this, a draft operational concept of innovation in the role of the office of the ombudsman are proposed.

First part -initial considerations about innovation
Conceptual definitions about Innovation have been described in the literature of several fields of knowledge, especially since the initial work of Joseph Schumpeter at the beginning of the twentieth century [3][4][5] .In his works, and particularly in his theory of the economic cycle, the above author is of the opinion that it is a non-linear dynamic system and basically classifies inventive transformations tested seasonally by the Economy -so-called innovations -into radical (characterized by provoking major changes of a structural and/or even revolutionary nature), or incremental (characterized by promoting an optimizing process of change without traumatic upheavals, albeit in a continuous, fluid form).
However, the author distinguishes the difference between innovation and invention, within the scope of a capitalist industrial model of wealth-generation: an invention is an idea, draft outline or model for a new or improved artefact, product, process or system.An innovation, in the economic sense, is only complete when a commercial transaction occurs involving an invention and thereby generating wealth 6 .
So, the author raised innovation to the status of a dynamic element of the capitalist system.When it experiments with an alteration provoked by an innovation (the discovery of new raw-materials, the introduction of a new consumer good or of an inventive method of producing merchandise, a practice or process that alters the structure of an existing market), this significantly upsets the homeostasis or state of equilibrium of the system, and a process of expansion (a boom) encounters the conditions it needs to thrive.However, because of this entropic propensity, the innovation process consists of creative destruction, encountering a possible analogy with the ideas expressed in the astrophysical/cosmological theories of the Big Bang, and the Big Crunch and, even, with the ideas of Anthony Giddens, who used the metaphor of the juggernaut, based on the Hindu story of the wagon of the Sanskrit warlord, Jagonnatha, in his book called "The Consequences of Modernity." In the wake of the debate on Innovation and the innovative process, which began with events that occurred in the aftermath of the period of colonialist and imperialist industrial Capitalism prior to the First World War, during which Schumpeter lived, several social scientists (notably economists and sociologists) have revised, updated, adapted, revamped, refined and, even, renewed their thoughts on this issue, as is the case, for instance, of Christopher Freeman 7 and Peter Drucker 8 , among others.
Known as "neo-Schumpeterians," from the end of the 1960s and 1970s, and in the context of the second major world oil crisis, biological analogies were disseminated along Darwinian lines to explain the supposed evolutionary character of capitalist development and, in particular, the process of technological change.Following on from this line of thought, the idea is propounded that innovation is the key determinant of economic dynamics, valuable in defining organizational standards, competitiveness and entrepreneurship and in establishing productive cooperation.This is especially true in the current synergetic environment where there has been an increase and acceleration in relationships in a world that, since the late twentieth century and early twenty-first century, has become ever more interconnected.
As academic Innovation theories have been developed, the Triple Helix theory on development (involving government, universities and industry) has achieved a certain prominence, in spite of its inaccuracies and limitations.These were derived from the fact that little emphasis is placed on analyzing institutional formats underlying each innovation process, as well as the relative social, economic and cultural impacts that these produce 9 .Thus, it is obviously of strategic importance to be able to identify what produces, generates and sustains innovation.

The Interconnection between Innovation, Information and Knowledge
At this point, a consensus is reached that notions of information and knowledge form the basis of the origins and development of innovation.Thus, the production, the systematization, the interchange, the exchange, promotion and dissemination of information and knowledge between individuals, groups, institutions, organizations and even countries, are expressed by the capacity for interactive learning, that makes it possible to face the constantly-changing difficulties of daily life, as well as establish strategies to evaluate processes, performance and/or outcomes 10,11 .
With specific reference to knowledge, it is worth noting that it is not only the formal/formalized that is part of the process of innovation since, even knowledge that is informal and non-structured, constructed along sociocultural practices inherent to the most basic and day-today processes of sociability, has a strategic and substantial role to play.Thus, their asymmetries, their character of uncertainty and incompleteness and their complexities cannot be ignored.In this particular case, the Actor-Network Theory and the subject of Sociology of Innovation have produced interesting analyses, such as the work by Bruno Latour 12 and Manuel Castells 13 , with their concepts of Translation (or Mediation) and Networks, respectively.
In the case of Brazil, from the second half of the 1990s onwards, the idea of innovation has been viewed with special interest and widely incorporated into public and private sector practices 3,5,11,[14][15][16][17][18][19] .Even so, it may still be necessary to consolidate an interpretation of this concept in the sense of ensuring its incidence and operationality in public policies -especially with respect to the work of the offices of the ombudsman of the SUS, in an effort to expand, consolidate and disseminate the excellent innovative performance observed in such niche segments as that of the economy, which are viewed as strategic and where the role of the State has a positive effect (Embrapa, Embraer, Petrobras, etc.).

Possibilities of operationalization of the concept of innovation in public management
There is an enormous variety of conceptual definitions in the vast literature that exists about innovation, which is always notable for its multidimensionality.It is interesting to note that studies indicate that there is a difference between innovations that have been "invented" and innovations that have been "adopted," the former having been spearheaded by the very offices/organizations that applied them, and the latter being characterized by a mimetic-anthropophagic movement.In fact, according to some authors, the latter type seems to be the one most commonly found in the public sector 3,4,20 .
According to the Organization for Economic Cooperation and Development (OECD), in the document entitled the Oslo Manual, innovation is … the implementation of a new or significantly improved product (good or service), or a process, or a new marketing method, or a new organizational method for business practices, the organization of the workplace or foreign relations 21 .
However, Brazilian legislation on innovation defines this in a very direct way as the introduction of a new feature or improvement in the productive or social environment that results in new products, processes or services 22 .This implies that it is becoming increasingly clear that Science and Technology are fundamental for the development of conditions for welfare and Health, although safeguards relating to politico-ideological, sociocultural and socioeconomic precepts should always be considered.Innovation is the key issue in this scenario, and understood as being less dependent on technical ingenuity, and more dependent on establishing information and knowledge networks of production, circulation and transformation.
It has now become possible to think in terms of an organizational culture that is moving towards a culture of innovation, since this will encounter ideal conditions where it can develop within an organizational environment, characterized by the existence of creative spaces and an effective system of interpersonal communication, which make it possible to share ideas, skills, information, knowledge, experiences, experiments and values [23][24][25] .
The idea that information, in itself, does not generate knowledge, given that it does not present the inherent capacity to alter cognitive structures, is consistent with the notion of innovation as advocated in this respect.
Allied to this, it should be remembered that issues, such as indetermination, inconsistency, instability, risk, uncertainty, diversity, namely themes that arise frequently in contemporary social thinking, become an important part of the way that the process of innovation is discussed, from the perspective of the relationship of analysis of productive systems to analyses made within the administrative environment of public management 26 .
When relating theoretical-conceptual reflection on innovation and the innovative process to the decentralization and municipalization process in the area of Healthcare in Brazil, Fleury 20 makes an interesting observation about the studies produced by several authors, in the sense of questioning the notion that a bureaucratic management profile would in principle exclude the possibility of promoting innovation and/or the innovative process.
It is surely not that unusual or surprising to see that, if progress and change -in short, innovation -transcend the stability of the status quo, that the same could not be expected from a bureaucratic system as a transforming agent.It is worth recalling that "bureaucracy" is a term formed by the French word bureau (meaning "office") and the Greek word krátos (meaning "power" or "rule"), which, over time, has acquired a derogatory meaning implying rigid controls and superfluous and counter-productive rules in relation to the fluidity of a system or a set of actions and procedures.However, despite this, it is even more surprising to note the paradox contained in the fact that change cannot dispense with flexibility and the support of stable elements.
Thus, in an environment that is open to change, innovation may occur, and this is more likely to occur than in an environment that is mired in complexity, that stifles and prevents opportunities from arising.This ties in with the idea that governmental organizations, traditionally and historically considered to be overly bureaucratic, centralized and resistant to innovation, also have the potential to produce positive and unexpected outcomes when this involves spearheading innovative procedures.
In connection with this question, when outlining his ideas for local health management, Fleury 20 introduces the concept of Social Innovation: ... it is the process of transformation and densification of the public sphere and refers to the expansion of citizenship by means of the threepronged process of integration, participation and distribution, involving -as its primary outcomethe possibility of creating autonomous and emancipated individuals, whose insertion in the public sphere is constitutionally defined.Thus, the more innovative a public policy is, the greater its capacity to concentrate high levels of integration, participation, distribution simultaneously.
Following this train of thought, with the aim of revealing and evaluating Innovation in Healthcare, Fleury states that policies have material, institutional and symbolic dimensions; as a result, they work with three dimensions of innovation applied to public management that present an interesting possibility of discussing the innovative process within the scope of experiences of the office of the ombudsman.
The first Social dimension refers to the relationship between public authorities and society that increases participation in defining priorities and in the design of public policies, effective social control, rendering accounts, and the responsibility of public servants -in other words, Accountability.
The second Management dimension deals with the introduction and/or maintenance of innovative administrative procedures in municipal management, so as to increase their efficiency and effectiveness, thereby enhancing procedures and the use of internal and external resources, as well as tools of information to balance supply and demand.
The third Care dimension includes different actions and/or programs that are differentiated for that which is usually known as "cutting edge," that is to say, management tools that aim to increase the quality and effectiveness of healthcare, as well as the introduction of new programs and actions encouraged by central government 20 .
Having presented these considerations and based on these same thoughts, reflections will be presented in the second part of this article, that are geared towards the operationality of adopting the idea of innovation in the Offices of the Ombudsman of the SUS.

Second part -building a task-force of ideas of the office of the ombudsman and the proposal for innovation in the Offices of the Ombudsman of the SUS
A great deal has already been produced in the literature about innovation.This can be understood from a corporate standpoint as a process to discover problems with a market value and the search for solutions, through trial, error and permanent network learning.It can also be understood as institutionalized dissatisfaction with the institutional status quo … It is imperfect, incomplete and impermanent 27 .Therefore, from this approach, it may be understood that innovation contains a dialectic character of change, involving an attitude that is at the same time the result and instigator of co-leadership of all those involved, of sociotechnical significance when dealing with information and the production of knowledge 15,19,24,25,28,29 .
The concepts that were presented in the first section of this article represent the initial elements of a discussion about the nature and functionality of the office of the ombudsman within the Unified Health System (SUS), for the three spheres of public administration, taking into account the changing context, the high-speed transformations and characteristic complexity of contemporary life.
For the purpose of discussing the possibility of the office of the ombudsman operating within the Brazilian healthcare system and constructing a concept of innovation that can be consolidated into SNO-SUS practices, a proposal was reached for establishing a Task-Force of Ideas for the Office of the Ombudsman: An entity that prepares adequate responses that combine the concept of problem-solving for issues relating to grievances that cover: 1) Mediation Phase, that involves receiving grievances and monitoring these together with the appropriate and competent offices/organizations; 2) Processing Phase, that involves receiving, holding, forwarding, analyzing and making use of information and knowledge.
In order that such a task-force of ideas can be overseen by the office of an ombudsman in a way that is viable and feasible, an understanding about what this office actually represents and what potential it can offer while it has the ability to function as an innovative entity should include the following aspects: . Characterizing Features -These are expressed by institutional factors that refer to the Structure of the Offices of the Ombudsman (its installations and physical, human and virtual resources), the way they process information related to Proceedings (their basic day-to-day methods of operation in systematically dealing with incoming grievances), and the process of mediation in relation to the Outcomes obtained (relating to the effectiveness of their actions and the way they resolve problems that generate the grievances).
. The Concept of an Active Ombudsman, which is defined as the capacity to promote efficient strategies to listen to citizens, not only in the way they receive their grievances through the normal access channels, but also investigating information to support management and social control.This idea is an integral part of the notion of proactivity, substantiated by what some actors call the "Proactive Ombudsman," as opposed to the passive nature of a "Reactive Ombudsman" 30 .
. The Notion of Regulation applied to the practices of the Office of the Ombudsman, adapted from the related theory and the juridical-legal concept of regulations, obeyed and managed by the institutional regulatory apparatus (audit and control organs, Court of Auditors, Regulatory Agencies, Public Prosecutor's Office, Attorney-General of the Union, Councils, Ministry of Health Departments and Offices of Regulation and Coordination, among others) 24,25,31 .
It has been shown that the idea of innovation in the role of the ombudsman, or of an innovative ombudsman, should take into consideration Social Participation and Control, Governance and Regulations and the potential of Information and Communication Technology (ICT) and social networks -as they are all based on human resources, software and hardware 15,16,24,25,29,32 .
It is also necessary to be aware of the question of participation merely when it is employed as a form of "participationism," that is to say, when it gives citizens a voice and even listens to them, but without effectively resolving the issues that led to their grievance.This is an idea that needs to be overcome, a challenge that must be faced and an enigma that should be resolved!This enigma translates into the need to overcome a certain form of paternalism or participative behaviorism without falling into the trap of the exclusionary interactionist notions of Government and Nation-State.The work of the Offices of the Ombudsman must always be to deal with Public Policies and mediation procedures in response to grievances filed by citizens who face tangible problems, that range from the most specific and mundane to the most complex and structural, from the point of view of access to medication and services and to the wider issues of public management and administration.
Thus, the expected is for the innovative role of the Offices of the Ombudsman to develop agility and flexibility in the way they respond to grievances, overcoming bureaucratic systems and always seeking to achieve self-enhancement in all areas that are an intrinsic part of their work.It is also desirable that alliances are formed with actors who hold restrictive and sanctioning powers, developing articulate problem-solving abilities for mediation procedures via the regulatory network that responds to public grievances, whatever these may be.Similarly, as agents for transformation imbued with social responsibility, they should offer strategic actions and, together with citizens/claimants and other agents from established networks, demonstrate their ability to resolve disputes, as expressly required by those filing such grievances, in whatever situation.
In order for this to happen, a fundamental issue is involved: The understanding that what is produced as a response from the office of the ombudsman with respect to a grievance, involves a consensual outcome.Thus, the idea of participation involves cooperation and must have reflexivity.
With all these points for reflection an initial proposal was reached for an operational concept of innovation in the role of the office of the ombudsman: Interpreting, processing and disseminating information and knowledge that support management and the citizen, and articulating and developing a Regulatory Mediation Service Network, including both physical and virtual elements, in an ongoing and organic process of self-enhancement.
In order for this concept to be operational-ized, it is therefore necessary to ensure that the information management system of the office of the ombudsman is adequately designed and structured, in accordance with this concept of innovation in the role of the office of the ombudsman, such that the technical expertise is consistent with the work implemented.Information management should be based on organizational policies that promote harmony and inter-relationships between the institutional units or sectors.From this perspective, information is an important asset that institutions possess for the production and sharing of knowledge.
In 2003, the Twelfth National Health Conference voted in favor of preparing and implementing articulated healthcare information policies for the three spheres of government, guaranteeing greater visibility for SUS guidelines, for health policy, actions and the use of resources, with the aim of increasing social participation and control and meeting the demands and expectations of Brazilian society.These policies were outlined so as to reinforce the democratization of information and communication, in all aspects; to guarantee the compatibility, interface and modernization of the SUS information systems and to improve integration and articulation with data base systems that are relevant to the healthcare sector 33 .
In view of the definitions established at the Conference and acknowledging that the SNO-SUS information management is included within this group, discussions involving innovation in the role of the office of the ombudsman in healthcare should consider the following: • The organization (and systemic and systematic analysis) of the data collection process, storage, organization, analysis and production of information and knowledge for the SUS; • The definition of parameters and indicators based on information that is produced and that contributes towards the systematic and regular assessments made of SUS healthcare processes and outcomes; • The information management method to be established in the three spheres of government in an articulated and integrated manner; • The democratization process for the three spheres of government, providing access to information and knowledge produced by the SNO-SUS.Thus, it is not sufficient in itself to store the information that the office of the ombudsman receives (be this either as the result of citizen grievances -the grievance itself, be this the response it gives to the citizen in question -or information produced through other means) in well-structured data banks and platforms.
In addition to storing information, it is not enough merely to transform it into knowledge (be this for management, or for the citizen, or for academia) by preparing analytical reports, which are readily accessible and transparent.
Much more is always needed.It is necessary to transform the regulatory mediation network into something that is organically vibrant, establishing mutually empowering partnerships with the actors involved (institutions and government agencies that are part of the three spheres of public administration and civil society), who are capable of producing this work jointly thereby showing that it is possible to resolve the problems that these grievances highlight and represent, in the shortest time possible.

Collaborations
Establishing these partnerships and ensuring their sound implementation depends on the political actions of managers and technicians imbued with the perception that seeking innovation is inherently very innovative.It should involve innovation that implies immediate benefits for each individually involved party, for the fully articulated network and for the SUS, as these grow stronger and gain greater legitimacy and, last but not least, for the citizens, as they will have their right to healthcare guaranteed.

FMB
Fernandes, MR Moreira, JM Ribeiro, AM Ouverney, FJF Oliveira and MFA Moro worked on the concept, research, methodology and final text of this article.