Management of Primary Care : a challenge for international cooperation in health

The need to resolve immediate problems in basic healthcare systems and the decisions that must be made in the daily management of healthcare centers must reach beyond awareness of common sense, and be reinforced by the evidence sought in scientific knowledge that will provide a new look at the facts and phenomena that happen on a daily basis. This article examines an experience of triangular cooperation in health between Angola, Brazil and Japan, which took place in Luanda, Angola between 2011 and 2014. The “Project to Strengthen the Healthcare Through the Development of Human Resources at the Josina Hospital and in other Healthcare Services, and to Revitalize Primary Healthcare in Angola (ProForsa)”, with the involvement of Fiocruz as the party executing the primary healthcare component. This is an innovative role in technical cooperation as a tool of political action. A training program with multiple possibilities enabled technical-political partnerships in an approach for “structuring cooperation in health”. The article analyzes how interventions in international cooperation in health management may create scientific evidence that, together with the local political context, can transform organizational elements such as healthcare centers, their clinical management and physical infrastructure.


Introduction
International technical cooperation is considered an important contribution for the social development of countries of moderate to low income, and an important component of Brazil's foreign policy, especially regarding countries in Latin America, the Caribbean and Africa, focusing primarily on the Portuguese Speaking African Nations (PSAN, or PALOP in Portuguese).Ever since the 1978 Buenos Aires Meeting, sponsored by the United Nations Development Program (UNDP), which reviewed technical cooperation among developing nations, Brazil has expanded its role in south-south cooperation.It is the view of Brazilian diplomacy that south-south cooperation should not limit itself to reproducing the traditional mechanisms of north-south care techniques, but rather it should look for joint efforts to enable solving the problems of the countries involved in cooperation, in areas where Brazil has already experienced positive results 1 .
South-south cooperation has the potential to promote the meeting of different institutions that must deploy concrete change processes in their geographies.In this field, the focus of international cooperation in health has varied, and has been based on different concepts and methodologies to achieve development 2 .The main goals of Brazilian cooperation in Africa and in Latin America focus on training human resources and developing the capability to strengthen or create strong institutions suited to reviewing and rebuilding the healthcare system ("structuring institutions").For the concept of structuring institution see Almeida et al. 2 , and Buss et al. 3 .The field that permeates all international cooperation programs, especially those in the area of primary healthcare services, should reflect on the "criteria that characterize vulnerability in this context: limited country ability to do research, the poverty of the people or populations, access to healthcare services, population education, and conditions related to gender, ethnicity and place of domicile" (Santana e Lorenzo, 2008, p. 156).The need to resolve immediate problems in basic healthcare systems and the decisions that must be made in the daily management of healthcare centers must go beyond awareness of common sense, and be reinforced by the evidence sought in scientific knowledge, which will provide a new look on the facts and phenomena that happen on a daily basis.
As part of this milestone, between 2011 and 2014 Brazil was involved in a 3-way cooperation program with Angola and Japan (ProForsa), in which Fiocruz provided the primary care component for the project, based on experience developed at ENSP, the Sergio Arouca National School of Public Health Center, and EPSJV, the Joaquim Polytechnic School of Health, both part of the Foundation.Project to Strengthen the Healthcare System through the Development of Human Resources at the Josina Hospital and in other Healthcare Services, and to Revitalize Primary Healthcare in Angola (ProForsa).
The option was made for a multi-dimensional Training Program on four dimensions: 1) Promoting and being a catalyst of the required competences and capabilities; 2) Integrating and coordinating the involvement of institutions, bringing managers, professionals and the population together (intersectoral actions), based on 3) recognizing that health and disease are both biological and social phenomena, in this case because they result from social, political and environmental determinants that coexist within the same geography (expanded healthcare concept), and 4) measures to protect and promote health should be associated with patient care (integrated healthcare).The program should be applicable to Angola and suitable for replication, contributing to reorganizing primary healthcare in the capital (Luanda), and transforming the care model.ProForsa thus combined policies, plans and programs within the nation's governance and technical proposals and guidelines already tested internationally, in this case in Brazil.
This article addresses the innovative role of technical cooperation as an instrument of political action, based on structuring technical-political articulation in health, and analyzing how international cooperation interventions in the field of health management may lead to scientific evidence that, in the local political-institutional context, may transform a given organizational locus.In other words, organization of healthcare centers not only from a clinical management point of view, but also from their very physical structure.

Solidary project
ProForsa was proposed after the government of Angola verified very little impact on the population of some international cooperation projects in terms of the response of healthcare services.ProForsa was coordinated by the Angolan Ministry of Health (MINSA), the Ministry of Foreign Trade's Brazilian Cooperation Agency (ABC/ MRE), and the Japan International Cooperation Agency (JICA).The Oswaldo Cruz Foundation was responsible for the Primary Care component, and the State University of Campinas (UNICAMP) handled the Tertiary Care component.
At first, Angola asked the Japanese government for non-reimbursable financial cooperation to restore the facilities of the Josina Machel Hospital, the nation's reference facility, and the Lucrecia Paim maternity hospital.By the end of the restoration step, it was evident that professionals had to be trained to improve the quality of the services those institutions provided.In 2007, a first initiative in three-way cooperation between Angola, Brazil and Japan took place, executed by the State University of Campinas (UNICAMP), which for three years trained over 750 healthcare professionals in hospital administration, image diagnostics, nursing and clinical labs.In 2010, at the end of the 3-year period, with the facilities recovered and a reasonable number of people trained, new needs were found, as patient demand had increased at both the central and maternity hospitals, overloading the services.
This gave rise to the ProForsa proposal to expand the qualifications of professionals in tertiary care, and extend qualification to the staff of primary healthcare centers in Luanda, focusing on the components of organization and management.Regarding primary healthcare, from the onset Fiocruz proposed that the policies, plans and programs of the national governance area be combined with proposals and guidelines emerging from technical cooperation, with a strong integrating component to strengthen primary healthcare and consolidate a project to revitalize the Angolan Healthcare System.The goal was to promote correspondence between the proposals of a new Healthcare model and training programs, reorganizing the working processes of healthcare centers and the relationship between these units, the population and the tertiary (hospital) sector, based on a critical dynamic.

Participative formulation/negotiation
Fiocruz develops its international cooperation activities along a horizontal agenda of international cooperation prepared by the Ministry of Foreign Affairs' Brazilian Agency for Cooperation (ABC/MRE), using the concept of structuring cooperation in healthcare 2 , which advocates for strengthening the healthcare system institutions in partner countries.This concept and purpose have formed the model of shared responsibili-ty among all players from the start of ProForsa negotiations, supported by the framework of the Angola National Healthcare Plan (PNS) 5 , and the Guidelines for Cities prepared by the Provincial Healthcare Department in Luanda (DPSL) 6 .
Numerous authors have discussed three-way cooperation in which Brazil is one of the members.Pino 7 believes that emerging nations such as Brazil may use triangular cooperation as a tool to support south-south cooperation (SSC), increasing the scale of projects and exploring complementarities with other international organizations and nations.Abdenur 8 stresses that triangular cooperation emerges as an intermediary form between bilateral and multilateral cooperation, often assuming the form of a network of cooperation between different partners.Pessoa et al. 9 report Fiocruz's experience in a triangular cooperation project in Haiti, whose purpose was to increase the efficiency of utilization of available resources, increasing the effectiveness of project implementation and goals.While ProForsa includes all of these elements, it is important to point out other aspects related to the local political and institutional scenario that, once accepted by the parties, worked in favor of the proposal developed by the Fiocruz team: • Solidarity, recognizing the major effort of national restructuring undertaken by Angola after two wars (the war of independence and a civil war); • Structuring international cooperation as a practice, developed by Fiocruz, that reinforces national healthcare systems and values the local capabilities of its partners; • The need to train a healthcare workforce, as in Angola many of the professionals providing such services have had no opportunity for specialization; • The explicit need to restructure Primary Healthcare, the gateway to the healthcare system.
• The possibility of developing a methodological proposal using dialog and valuing the accumulated knowledge of practice players to build new knowledge; • The possibility of adding knowledge to healthcare organizations in light of the new needs, supporting policy formulation and the decisions upon which change should be deployed.
By inserting itself in the horizontal international cooperation model, based on strengthening the endogenous capabilities of the partners, ProForsa sought to be consistent with the notion of solidarity permeated by a discussion of alterity in its possible actions: conflict, assimilation, tolerance and understanding (Magnoli, 2008).In this way, it stressed the option for the last component of alterity or, in other words, solidarity that seeks to recognize and understand the other in its different dimensions and needs.
Structuring cooperation in health seeks to combine concrete interventions to build local capabilities and generate knowledge, promoting dialog among the players to allow them to become the leadership protagonists in healthcare processes, and foster the independent formulation of an agenda for sector development 2 .To bolster the possibility of restructuring the Angola healthcare system, ProForsa developed an innovative aspect defended by the Fiocruz team: two committees made up of representatives of the three partner nations to ensure the political sustainability of the project and it organized and shared undertaking: -The Joint Coordination Committee assigned to support the annual Project working plan, monitor annual progress, track and exchange opinions to address issues emerging during Project implementation, and discuss any relevant topic for the efficient implementation of the project; -The Implementation Committee, made up of the institutional players that execute the Project, plus strategic local players with management capabilities to ensure that the proposals are included.Its responsibilities are to prepare the annual Project working plan, submit the plan to the Joint Coordination Committee, coordinate working plan implementation, monitor and assess the activities performed by qualified workers, identify and propose solutions to problems that may emerge during project implementation, and discuss any issue relevant to its efficient implementation.
The two Committees were defined based on a consensus between the countries involved, and were active throughout Project Implementation, helping align it with unique aspects of local policy and the desires and expectations of the partners, adjusted to the purposes of the project.Meanwhile, the Committees approved and monitored budget execution and the development of all subsequent steps in the project.

Implementation: methodological innovation in cooperation
Not all healthcare centers in Luanda have the same mission, although they have the same healthcare programs and are guided by the same national health policy.Their unique aspects de-pend on a range of variables.Based on this reality, there emerged a concern with not submitting a single training model, but to share comings and goings in a process marked by two principles -that group participation is necessary for transformation, and that the healthcare model should be one that meets the true needs of the community 11 .Based on its training/organizational learning experience in healthcare units in Brazil, from the very start the Fiocruz team chose to contribute to the development of workplace training processes to seek effectiveness in how Luanda healthcare centers respond to the needs of the community.
Based on the demands of Angola, the Fiocruz team opted for a Program of Training in Primary Healthcare Management that includes developing different themes as part of a core training axis, rather than merely a course.This decision was made based on the multiple possibilities enabled by this way of organizing training processes, and the fact that it is more efficient and the outcome more effective.The expected results of an arrangement such as this would not only enable professional qualification, but also seek to integrate the various players -those responsible for articulating the creation and revitalization of the services-, so that they interact with each other to achieve institutional development.
This methodological approach is in the field of knowledge of Collective Health, which according to Paim 12 involve a set of technical, ideological, political and economic practices developed in academia, in healthcare organizations and research institutions linked to the different currents of thought, and resulting from health reform projects.According to the author, this implies in deeper exploration of the following dimensions: the health status of the population and general trends in epidemiology, demographics, socioeconomics and culture, healthcare services as institutions of different degrees of complexity and different working processes, formulating and implementing health policies and analyzing plans, programs and technologies, in addition to health and healthcare knowledge, including historical, sociological and anthropological studies on the production of knowledge and the relationship between scientific knowledge and popular concepts and practices in healthcare.
Based on this reference, when formulating and implementing the plan it would be consistent for the team in charge of execution to select a specific training and pedagogical model, based on a previous assessment of local needs, and an analysis of the official documents pro-vided, which enabled understanding the Angolan healthcare system guidelines and policies, the development of the Angolan healthcare plan, the more critical analyses and a preliminary diagnosis of the country's needs, as a first step in the project.
Before the program could be implemented, criteria had to be defined for selecting the four pilot units -the Samba, Cassequel, Terra Nova and Ilha Reference Healthcare Centers (R-HCC).This step included representatives of the Fiocruz team and Angolan authorities.Students were selected by applying a number of criteria based on the concept of strengthening learning and organizational skills, resulting in a group of willing professionals with a degree of technical knowledge and governability to implement changes in the working processes.
Following an initial diagnostic, a seminar entitled The political-institutional context of Pro-Forsa: recognizing players, re-agreeing on responsibility for actions was held in Luanda, proposed and coordinated by the Fiocruz team from the onset, believing that the program to be designed should consider students as political and social agents, rather than merely healthcare technicians.This required a team willing to break with the traditional dynamic of the teacher-student relationship and go beyond respect and solidarity to recognize and address the concrete, day-to-day problems of the Angolan players, often not part of the life context of the cooperating technicians.

Solidary cooperation -learning together
Therefore, the project's pedagogical project sought to create proximity among managers, professionals and the population to enable recognizing that health and disease are both biological and political-social projects that coexist in the same geography, and that actions to protect and promote health must be combined to those that currently focus on patient care.The first step of the training program was an effort to combine the development of technical capability and service efficacy and efficiency.This understanding is the basis for a future step that addresses the consistency and optimization of the budget.
As the pedagogical method we chose the method of Freire, or problematization "critical-participative pedagogy" 13 .This method addresses the development of knowledge based on experience and supported by discovery-based learning processes, rather than receptive models 14 .This learning occurs through determined action, learned is the result of a critical level of knowledge achieved through understanding, reflection and critique, rather than the pure and simple "transfer" of concepts.
To put these theories into practice we used teaching and learning theories capable of capturing interest, and causing reflection and questioning, and above all leading to new knowledge.This included technical texts written or adapted for this training program, audiovisual resources, classroom activities, technical visits, case studies, group discussions, spoken maps, conceptual maps, dramatizations, the Internet, and data geoprocessing, including the organization of the space-geography used as the "classroom".
For the program structure, we opted for a modular system that would enable developing face-to-face and distance activities, as well as activities scheduled for the dispersion periods.This architecture enabled adding other professionals to each model, performing standard activities aligned with the scheduled content.The organization was comprised of a total of 10 modules applied over the three years of the project.Learning Units were created for each module to ensure logical cascading, systematic presentations and scheduled content discussions.
In this sense, training must also rethink the outcome.In the overall context of program assessment, "products" are defined as the direct outcome/effect of the activities performed for a given goal.In terms of ProForsa, what is known as "products" is intrinsically related to student training and the opportunities developed, based on critique, discussion and consensus, to positively intervene in the reality of the four R-HCCs addressed by the three-way cooperation for primary healthcare.
The first three modules of the Training Program focused on "learning-action", Methodology for Analyzing Situational Strategic Planning and Context, building the following products: 1) Preliminary diagnostic of the healthcare center geographies; 2) Preliminary diagnostic of the healthcare infrastructure; 3) Two structural action plans, based on critical problems, with major governability on the part of the players linked to capability development.Thus, a discussion of the action plans defined the themes and contents included in the other Training program modules.Two critical problems were chosen: R-HCC deficiencies and inabilities, leading to disorganized care of major patient demands, and Limited efficiency of the data collection, analysis and filing system.

Lessons learned
The merit of the ProForsa products resides in the very real possibility of deployment across the entire nation of Angola, and their ability to contribute not only to reorganization of primary healthcare, but also promote change in the care model, bringing it closer to the principles and characteristics advocated by Primary Healthcare.
It is also worth pointing to the numerous suggestions made by students for structural reform of the four healthcare centers, proposed by sector municipal administration during the training period.Following the participative diagnostic, the trained local professionals were able to positively intervene in the infrastructure works underway, adjusting the new spaces to patient flows, sectored service, visual communication and furnishings.Activities in training enabled running a diagnosis of the health status and living conditions in the areas covered by each healthcare center, taking care to adjust, in as much as possible, the original facilities that had been scrapped and project changes favoring the working processes of the professionals involved in user services.
The development of an educational process to collectively build a proposal to intervene in healthcare services implies in a number of steps that oftentimes cannot be distinguished one from the other.In fact, they combine efforts and are, to an extent, an expression of the effort of combining the academic task of training (identifying and dialoging with existing theory) and anticipating the applicability of training to the real world, and sharing findings and the understanding of other players to create a continuous movement of queries, involving and committing institutions and managers at all three levels of power (local, city and national) The technical-political articulation of Pro-Forsa proves a gain that Brazil can capitalize on for future international cooperation efforts in primary healthcare, focusing on reducing inequality in healthcare for the poorer population.At the same time, this experience helped understand that implementing an intervention (revitalizing primary healthcare) will always be linked to the local political and institutional context, and integrating it into this context is subject to a given organizational locus that, most of the time, includes difficulties and problems inherent to the situation one wishes to overcome.Therefore, it would not make sense to ignore them when formulating and implementing the changes suggest-ed, but rather confront and understand them in all their nuances, and overcome them collectively and creatively.

Conclusions
The different instances of ProForsa (Angolan, Brazilian and Japanese) reinforce the importance of valuing not only academic development, but also the political feasibility of the process.Arah et al. 15 espouse the importance of good indicators and technical monitoring committees to improve healthcare, however, the strategy outlined by ProForsa, including Joint Coordination and Implementation Committees, was an innovation in terms of international cooperation projects focused on healthcare, enabling a dialog and systematic agreements that ensured the changes required for the project during the course of its development, and visualizing the institutional learning of the countries involved.
Exchange between countries in the area of healthcare, and the applicability of international cooperation projects to specific national realities creates actions that include elements considered essentially "diplomatic".In Brazil, this partnership has been expressed by the efforts of political diplomacy to support the nation's interests in global healthcare.This became evident once again in the support ABC/MRE gave Fiocruz as the executor, and the government of Angola as the final beneficiary.It was also a clear expression of what is known as "diplomacy in health, science and technology" through "structuring cooperation in health", which since 2009 has been the conceptual basis of Fiocruz, when it created its Center for International Relations in health (CRIS/Fiocruz).
Also important for developing an approach such as the one used by the Fiocruz team for ProForsa was its involvement in the entire process of developing the Brazilian "Unified Healthcare System" (SUS), which enabled the country to successfully provide better healthcare in the nation and, on the other hand, its experience in applying the learnings of the GERUS Project (Ministry of Health Basic Healthcare Unit Management Course), supported by OPAS and widely applied in a number of cities in Brazil 16 .The positive results of this nation-wide effort were widely visible, and the development of building partnerships has been important for the integration of partners in triangular cooperation activities.
Discussions on improving the management of primary healthcare are a relevant theme in public healthcare, the Brazilian approach bears in mind the social determinants of health in addressing the relationship between health and society 17 .In the 1970s this discussion was one of the main theoretical pillars of the critical thinking that created Collective Health in Brazil, which in turn was among the theoretical foundations that enabled creating the training program used by the Fiocruz team in ProForsa.
We believe the success of ProForsa was due to the inclusion in its scope of what Paim and Nunes 18 call incorporation, both in healthcare training and international cooperation in health, the perception of continuous evolution and growing complexity of the practices that organize healthcare.Therefore, one must constantly incorporate new technologies and define working patterns in this field which can change, but that must be added to healthcare systems to qualify human resources and reinforce their management development.
The case examined also enabled us to identify what Esteves et al. 19 called an attempt at the international extension of Brazilian experiences in public health, which carries with it conceptual choices (universal participation and access, among others), and chooses of policy that link public health and development in a broad manner.Thus, one realizes the contributions of the ProForsa project between Brazil and Angola went both ways, with valuable contributions from Japan.This learning is very important to improve primary healthcare in countries with healthcare systems that must be ready to respond to disease and to implement health promotion and prevention measures that include dimensions of group health.
This triangular cooperation allowed us to experience the "spirit of learning" brought on by adversity which, at times, happens in a relationship that includes different habits and cultures.Just as human experience that is constantly changing and renewing itself, this cognitive, material and affective construction enabled by ProForsa, using transformative methodology, will always require adjustments and adaptations to meet new and successive changes resulting from the movement and dynamics of the geographies involved.We hope that the professionals who participated in the ProForsa project will be constantly attuned, mobilized and committed to add and use new knowledge and new explanatory models to exercise best practices where they work.

Collaborators
MCB Figueiredo and CSBM Porto contributed with the elements relating to the ProForsa project itself, its negotiation, formulation and implantation, as well as the project conclusions.LE Fonseca contributed with the introduction and the discussions in the text that place the project in the context of a broader discussion about international cooperation in health.