Challenges of municipal planning from the perspective of nurse managers

Objectives: to analyze the municipal planning developed by nurses coordinating Primary Health Care, aimed at coping with Chronic Noncommunicable Diseases, from the perspective of the Situational Strategic Planning. Methods: a descriptive exploratory study with a qualitative approach developed in municipalities of a Health Region of Rio Grande do Sul State. Semi-structured interviews were carried out with the Primary Health Care coordination of the municipalities of the empirical area, between 2014 and 2015. Content analysis was the thematic and the theoretical perspective of strategic analysis. Results: in the development of municipal planning regarding care for chronic illness, the study highlighted fragilities, which are a challenge for management. The Regional Municipal Planning is a tool that contributes to the articulation between actors involved in the organization of the health system. Final considerations: strategic insertion of Nursing in the field of Health prompts the debate about the role of this professional in the management of SUS. Descriptors: Health Planning; Public Health Nursing; Primary Health Care; Chronic Disease; Nursing Staff.


INTRODUCTION
Collective Health is permeated by the health care promoted by Nursing, in an inter and/or disciplinary way, with an undeniable role held by nurses in identifying and intervening in the health needs of the population, as well as in the promotion and protection of health of individuals and collectivities ( ¹ ) . Nursing, as a social practice, has much to contribute with the Brazilian Unified Health System (SUS -Sistema Único de Saúde), in which certain tools are important, such as Health Planning, an essential tool for the managerial process ( ² ) .
Planning helps the management of the municipal administration, thus contributing to a better use of opportunities and overcoming challenges in the implementation of health policies. In addition, planning facilitates the definition of objectives, the organization of actions, the monitoring, the control, the expenses control and the evaluation of results ( ³ ) . From this perspective, promoting discussions that qualify the planning and, consequently, the managerial process of nurses who work in management positions in the context of Primary Health Care (PHC), is relevant for Collective Health and for the qualification of its practices within the field. Best practices in nursing care are related to the best performance of health services, thus using the available knowledge seeking to achieve success in health actions (4) .
In this study, planning is understood from a strategic and situational perspective, which promotes the conciliation of action in relation to a complex reality, integrating the vision of different social actors and the use of operational tools in analyzing and coping with problems (5)(6)(7) . Situational Strategic Planning considers the different actors in a conflict and cooperation game, in which each one sees the reality from their perspective of the situation (6) . Strategic thinking construction provides for thinking through method and before acting, explaining its possibilities and feasibility, proposing goals and projecting the future (5)(6) . Planning allows one to meet the demands of a given reality, to transform and move it, to achieve the desired objectives ( ² ) . The importance of the nurse manager's or coordinator's perspective must be emphasized, regarding the different approaches of the situation in the appropriation of the population health needs, so that planning suits the reality of the population.
In this perspective, dialogue about planning and chronic diseases is justified when it shows that Chronic Noncommunicable Diseases (CNCD) cause a high number of premature deaths, loss of quality of life with a high degree of limitation in work activities and recreation. At the community level, it causes economic impacts to families, communities and society in general, aggravating inequities and poverty (8) .
Brazil, since 2014, has formally instituted initiatives to act against CNCD. By means of an ordinance, it redefined the Health Care Network (RAS -Rede de Atenção à Saúde) of people with chronic diseases within the SUS scope, and established guidelines for the organization of its care lines, in a more organized way to the performance of comprehensive care (9) . Epidemiological data indicate that 74% of deaths in Brazil occurred due to CNCD (10) , which points to a challenging future for Nursing practices.
In order to think about effective preventive actions and supporters of CNCD promotion and coping, it is necessary to monitor risk factors and protect these pathologies (11)(12) , using tools to support planning and management of the health system in Brazil (12) . This setting can be reassessed from a strategic reading of the problem, aggregating different social actors placed in situation, from their ability to act, knowledge and interest on the analysis. The problem complexity now requires the reading of reality from different perspectives (5)(6) .
As for the insertion of nurses in PHC and in the practice of municipal health planning, they have developed skills and competences that gradually extend their action scope in the management of the health system from the local health services to municipal and state ones. This insertion demonstrates the double dimension of their work, both care and management, which should be focused on individual and collective care (13) . The nurse, in this perspective, acts as an important social actor, active subject and promoter of changes and even "produces reality and is the product of it" (5) . Nurse's best practices at PHC require that it is possible to rethink managerial work and care management, especially with regard to common health care problems, such as Systemic Arterial Hypertension and Diabetes Mellitus. In relation to chronic diseases, nurses can contribute significantly to the quality and optimization of health services (14) .
In this perspective, the production of knowledge that qualifies the work of these professionals in positions of municipal management contributes to expanding access to health services for people with chronic diseases. In this sense, Health Planning must be aligned with the demands of the population, constituted from a local and municipal situation analysis, in a collaborative way with clinical practice.

OBJECTIVES
To analyze the municipal planning developed by nurses coordinating Primary Health Care, focused on the CNCD confrontation from the perspective of Situational Strategic Planning.

Ethical aspects
Ethical aspects were respected regarding the access and analysis of data, taking into account the national and international norms of research ethics in humans. The Coordinators of Primary Health Care (CPHC) interviewed received and signed the Free and Informed Consent Form, in two copies, to confirm acceptance of participation in this study, as well as to guarantee their anonymity. Interviews were carried out in a day and place previously agreed with coordinators. Research was approved by the Research Committee of the Nursing School of Universidade Federal do Rio Grande do Sul (UFRGS), by the Ethics Committees of UFRGS and the Municipal Health Office of Porto Alegre.

Theoretical-methodological framework and type of study
A descriptive exploratory study with a qualitative approach (15) was chosen based on the theoretical perspective of the Situational Strategic Planning proposed by Carlos Matus. The objective was to build the study from the perspective of the social actors involved in the municipal planning, based on the nurses' PHC's municipal management position and its strategies to meet the demands of CNCD, as well as to overcome the daily challenges regarding the organization of services (5)(6) .
In this type of analysis, the bet is valued as a concept when explaining reality, in which the calculation is not based on the existence of laws, abdicating the determinism and objectivism of the prediction. Strategic analysis (5)(6) enables the different worldviews of different actors and puts them at stake, in which they struggle to modify results (reality). Despite the restrictions imposed by the past and the present, the world can be created and conquered in this game. This is the future that must be thought from reality, and not giving excessive importance to the past (5) .
In this way, it was intended to investigate the perceptions of the nurses who work in the management of PHC on the municipal planning, aimed at meeting the demands of chronic illnesses. These actors' perspectives provided the construction of an overview about CNCDs in the region of study health.

Study setting
The interviews were conducted between 2014 and 2015. Research was carried out in the municipalities of Alvorada, Cachoeirinha, Glorinha, Gravataí, Porto Alegre and Viamão, belonging to Health Region 10 of Rio Grande do Sul State ( Figure 1). This health region was chosen due to the challenges imposed by the organization of the health care network, especially regarding chronic illnesses (Chart 1), in the metropolitan region, thus adding the metropolis of Porto Alegre and large municipalities. Participants of this study were those professionals who occupied positions of managers at PHC of the mentioned municipalities; professionals that, throughout the text, will be identified as coordinators or managers. In these, this position of management was taken over, for the most part, by nurses. A total of nine professionals were interviewed, seven of whom were women. In order to meet the focus of this manuscript, it was decided to agree that, when dealing with the professionals interviewed, the term "female nurse" or "female coordinator" would be used, respecting the gender because most of the interviewees were female nurses.

Collection and organization of data and work steps
Data collection took place through semi-structured interviews carried out personally by the researchers with the aforementioned participants. Questionings were about organization and management of the CNCD in PHC and strategies adopted by coordinations to face the daily challenges of the organization of services.
Concerning data organization, interviews were recorded and transcribed in full for further analysis. The interviewees received the following coding: Coordination Primary Health Care Interview (CPHCI) -interviews with managers, from one (1) to nine (9).

Data analysis
Data analysis occurred through content analysis of the thematic type. NVivo 9 software was used as a support tool to promote the thematic categorization. Categorization was carried out from   the three steps proposed by the methodological framework, namely: pre-analysis, material exploration, and treatment of the obtained results and interpretation (15) . The thematic categories under analysis in this article will be presented in the results. Empirical was later discussed from the theoretical framework of the strategic analysis by Carlos Matus (5)(6) .

RESULTS
Results will be presented below, from the empirical categories "The nurse in charge of municipal management: challenges of municipal planning" and "The nurse in charge of municipal management: challenges for the management of care for chronic illnesses".
Of the coordinators or managers at the CPHC interviewed, the majority were nurses, and the choice to take the position was more technical than political. Before taking over the position, these nurses already worked in the municipality, having several assignments in the health department and knowing the reality in which they were acting.

The nurse in charge of municipal management: challenges of municipal planning
In the municipalities of the health region studied, there were disparities in the technical capacity of the coordination sectors to perform the planning and adapt it to the different local realities. Whereas some municipalities already have the organizational culture of using SUS planning tools, such as health plans, schedules and reports as mechanisms for the organization and integrated functioning of health services, others still find it difficult to implement these tools in the local organization of health actions. The fragmentation of planning is highlighted, when it occurs, as in the description of CPHCI 9, when it points out the development of its actions according to the programs developed in the municipal scope, but respecting the guidelines drawn by the Municipal Health Plan. The alternative identified by some coordinators to resolve the increasing demand related to the CNCD against the incipient panorama of financial resources and qualified professionals to work in this field was restructuring the health services, carrying out the transition of Basic Health Units (BHU) for FHS, in some municipalities, qualifying specific planning actions, which are intended for prevention. On the other hand, there are still municipalities that maintain, in a concomitant way, the logic of prompt care with the FHS care model. This entails a misunderstanding in the population regarding the care. [ The nurse in charge of municipal management: challenges for the management of care for chronic illness Some of the coordinators pointed out the difficulty of working in network due to the lack of articulation between the health services that compose the PHC. Even large municipalities of the Health Region studied did not have computerized and interconnected systems that could give support for more effective forms of communication. On the other hand, a relevant aspect to think about the management of the clinical practice at the local level of PHC teams is the interpersonal communication on the initiative of the local health services, which favors the articulation of the service to users. The search for more participatory ways of thinking about the local organization of health services delivery came from managers. Coordinators sought ways to optimize communication with the population through the health services teams, according to available resources, professional, and physical or financial resources, to approach the municipal management of PHC of the teams and the population served, starting from the territorial specificities and their health needs. [ At the opportunity of data generation, one of the coordinators mentioned a municipal project that aimed to help in mediating the communication among health services, encouraging the articulation of referral and counter-referral processes in the network, a strategy envisioned by the municipal management to attend in a more qualified way the situations of exacerbation of the chronic illnesses. Another element that emerges in the region under study is the lack of longitudinal follow-up of the demands that come from chronic diseases, both by the municipalities and by the MoH. Information on this topic emerged from the speech of one of the nurses, regarding the extinction of a precursor program of health actions directed to the CNCD, the HiperDia Program. This program assisted in the local organization of teams, but was not introduced in the daily routine of all health services. [ The aforementioned aspects can aggravate another difficulty that directly interferes with the possibilities of performing planning, which is an old insufficiency in the field of Health, access to data from the actions provided at municipal level, besides the non-computerization of some services that make up the RAS, mainly at PHC. These issues have been shown to be limiting in order to be able to monitor and evaluate the actions used to address chronic illness at the municipal and local levels. Daily service through local organization, planning of access, contemplating the demand suppressed by service, a consequence of the work overload caused by the multiple tasks of the professional that works at PHC were mentioned by the coordinators nurses.

DISCUSSION
When analyzing the data, it is inevitable not to stress which would be the best practices in the exercise of planning actions directed to meeting the demands imposed by the chronic illnesses and what is, in fact, performed. This is a relevant point, considering that the nurses who composed the corpus of analysis of this study occupy management positions in the municipalities, which demonstrates their role in proposing best health practices. In addition, this tool organizes the normative processes and health actions to be carried out, besides offering knowledge of the epidemiological characteristics of the population, essential elements for Health Management. Fragilities related to the organization of the local health system point to inequities in access to the service and, consequently, to the prevention and follow-up of chronic diseases that, if coordinated, could avoid the increase of related comorbidities. The findings presented in this article demonstrate that some of the municipalities have difficulties in performing Health Planning, according to MoH guidelines and recommendations. Thus, incipient planning entails, in the long term, effects on the organizational process of health actions, making it more complex, precisely for municipalities that do not have imbued in the work process to think their actions in the long and medium term, local level and municipal level.
In this perspective, through the view of strategic analysis, the MS operates, to a certain extent, through imposition, as a "normative directionality" (5) . This comes from strategic dynamics built from the implementation of administrative, programmatic and vertical norms (5) , in the present study, focused on PHC, municipal planning and challenges from the perspective of nurses managers in Health. This setting demonstrates the dissonance between what is instituted by the MoH and the capacity of the municipal level to better distribute the planning strategy in the SUS, even in municipalities with a tradition of adopting tools instituted by federal management.
In this way, the dual-track path of upward planning, of thinking the municipal from the local and the local acting in consonance with the municipal, is weakened in the sense that health services cannot make the situational analysis of their territories, which subsidizes the construction of health plans and schedules. The issue of insufficient resources may be the result, to a certain extent, of the difficulties of constituting the municipal planning tools of SUS in line with those of public budgetary management (7,(16)(17) . This inference does not deprive the reading of the current setting that is of containment of financial resources for the Health area, but points out that well-articulated planning with budget can optimize and qualify the expenditures in Health, as the unification of the blocks of health financing (costing public health actions and services and investing in the public health services network) requires greater accountability of states and municipalities, increasing the importance of the adequate construction of SUS planning tools (18) .
Organizationally, at SUS, these tools provide the health actions offered in the municipalities, also opening the possibility of social control to act in a more transparent way in Health Management, thus allowing the implementation of democratic processes with the Health Planning carried out. The study points out that noncompliance can be caused by problems and challenges found in the management processes by the public social actors responsible for them (19) . This instigates the need to insert these specificities in the training process of nurses, especially managers.
Regarding the incorporation of the specificities of CNCD in the planning of health care provided in the municipalities, there were important weaknesses in the setting under study, in relation to the organization of local attention to deal with these diseases. This is strengthened by the cumulative effects of inadequate management of Challenges of municipal planning from the perspective of nurse managers Reuter CLO, Maciel PP, Santos VCF, Riquinho DL, Ramos AR.
of CNCD care, evidenced by the emphasis on programming rather than Health Planning in a systemic and coordinated way. This may be a consequence of the organizational culture that favors the curative model of health care. Thinking about chronic illnesses and considering the absence of models of care based on evidence and needs, it is today up to managers to overcome their own professional limits and seek to address deficiencies in infrastructure, a deficient diagnostic and treatment support system (20) . If, on the one hand, municipalities present initiatives that are promising contextually, as more participative articulations between management, professionals and users as managerial tools that have systemic effects at the municipal level, very articulated by nurses, on the other, the diversity of initiatives of health services in the production of care for chronic illnesses is valued with regard to territorial specificities. Nonetheless, when there is no coordination of PHC in accordance with the SUS planning tools, the organization of municipal and regional RAS is impossible.
The theoretical framework of strategic analysis (5)(6) gives clues to the reflection and processing of the problems and setting presented, such as an explanation of how the problem arose and was developed; builds plans that interfere with critical "nodes"; assesses the political feasibility of the plan and how to make it viable; finally, it attacks the problem through operations built on the plan (6) . Strategic concepts that favor the transformation of this reality must be considered. The use of the tactic becomes fundamental in that it promotes the use of scarce resources to produce situational changes, as well as the strategy that predicts the use of this change to reach the objective situation (6) . In the case under study, the objective situation is the qualification of the municipal, regional and state planning and the interlocution of nursing in this process.
Currently, the Brazilian health system, seeking to promote a regionalized and hierarchical organization, in accordance with Decree 7,508 (21) provides that municipalities share geographical spaces that are close to locoregional specificities in order to organize, plan and perform actions and health services in a shared and supportive way. Thus, it is based on the new concept created by the authors of Regional Planning (22) , which is designed to account for actions and services in municipal and regional realities. This concept provides that health regions can be considered as devices where municipalities plan health care in a cooperative and solidary partnership, sharing successful experiences and problems that are common among them, but at the same time sharing health resources and services. This is an urgent need on a horizon that is very close to the municipal, regional and state administrations. The nurse manager's presence and performance in this process promotes the articulation of professionals and management in relation to best practices in the health needs of the population, providing the consolidation of policies that promote health and overcome the fragmented and curativist model.
Demands imposed by the CNCD show that health care could be articulated and planned regionally between municipalities. However, it is observed that there are difficulties in receiving rear of the State and MoH to organize their actions locally, due to the non-consolidation of health programs, such as HiperDia. A clue to the understanding of this problem may be related to political-governmental aspects that modify the Health Management setting in political transitions, including the difficulty of maintaining follow-up and sequencing of projects, especially in the Municipal Health Offices. This has consequences to the municipal planning in Health, since it makes difficult to organize a technical staff, program health actions and affects more perennial character of programs performed locally, especially for the lack of technical criterion in the selection of some managers (23) .
In relation to planning, when referring to social actors directly involved in the process and, in this case, political leaders, they demonstrate their way of thinking and doing politics through strategies adopted according to their political style, benefiting themselves and theirs, justifying the means for the ends or even the government by consensus (5) . This reality points to elements that also have effects on the longitudinal relationship of health care, interfering in the way teams promote care management. Currently, requirements in relation to planning and Health Management activities of the Brazilian population, mainly to users suffering from chronic diseases, presuppose the need for qualified and permanent professionals for their development ( ³ ) .
Facing the challenges for nurses who are coordinators at PHC, their insertion is considered strategic in the field of Collective Health, acting as important interlocutors for the performance of programs, coordinator and municipal manager. Thus, nurses are able to take over positions of decision and political health propositions, expanding their participation in health systems, due to their training that includes knowledge of the care and management area. With a view to comprehensive care, nurses have the potential to take over differentiated positions in the management of health systems (24) . In addition, in a study, approximately 46% of health unit managers held the title of nurses. This may be related to the knowledge of Administration in their basic training of undergraduate Nursing curriculum, that qualifies them to take over management positions (25) .
However, it should be mentioned that there are weaknesses in the work process of this professional in PHC, because although there is a need for nurses as leaders in Collective Health, the high turnover of these professionals compromises their bond with the community, quality of care and maintenance of the planning, causing work overload for those who remain in the teams, increasing the costs and weakening the processes (26) . In this context, the fact that the demand for care at PHC is increasing, makes nurses move their actions to routine activities and of level of complexity lower than their potential competences (27) . Regarding the difficulties related to lack of autonomy, failures in the information system, uncertainties and political-institutional uncertainties, and work overload, found in this study, corroborate with the national and international results that surround this setting (28)(29) . Also, one should not overlook the lack of availability of other professionals in taking on this role.

Study limitations
The focus of the study emphasizes municipal management through CPHC's view, which is a limitation of this study, because it does not comprehend the view of nurses working at health services, given that these actors are those who promote care for illness chronic diseases in the territories. Further studies should incorporate the perspective of the mentioned actors, seeking to of Challenges of municipal planning from the perspective of nurse managers Reuter CLO, Maciel PP, Santos VCF, Riquinho DL, Ramos AR.
foster the perspective that the Regional Municipal Planning (22) may be a common practice in health regions.

Contributions to the field of Nursing, Health and Public Policy
Nursing contributions to the field of Collective Health have been consolidated over time, so that, in order to advance in the production of knowledge about management practices within the CPHC scope, based on a referential such as that by Carlos Matus (5)(6) , strengthens the performance of nurses in this setting, as well as in the different spheres of Health Management.
Evidence points to the urgency of qualifying the Health Planning carried out to meet the CNCD, as well as to strengthen skills and competences, in the academic training of nurses professionals to act in the face of specifics that these diseases impose. The horizon must be regional and municipal planning in Health, considering that positions of local management of PHC were representative by the Nursing.

FINAL CONSIDERATIONS
The municipal planning analysis developed by CPHC under the perspective of chronic illnesses revealed initiatives and challenges to Collective Health Nursing. Regarding the initiatives, those of promotion to the organizational culture were observed by means of planning tools with periodic meetings, and using the municipal plan as guiding of local actions. The lack of financial and human resources are challenges to implement the planning of a model in Health that prioritize the continuity of care to the detriment of the acute care for people living with chronic diseases.
This study indicates that a permanent health care planning project is still needed for chronic sick people, and that nurses who hold management positions at the municipal level already have relevant theoretical and conceptual appropriation in relation to this practice, thus having much to contribute with this process under the SUS scope. The strategic analysis of Matus portrays the importance of knowing the setting to transform reality from the reading of the different social actors, seeking the objective situation to qualify planning (municipal, regional and state), in this study, starting of the local reality, regarding chronic diseases. In this sense, health regions can be thought of as devices that offer the possibility of municipalities that act in solidarity and cooperative partnerships, thus proposing a Regional Municipal Planning.
Nurses in charge of the PHC coordination demonstrate the strategic role of the profession in the different management areas of SUS and promote the reflection of strategies that can qualify the practice of these professionals, seeking the excellence of their practices. With this study, the possibility of broadening the knowledge of the performance of nurses managing/coordinating PHC is sought, advancing to consolidate this space as one of the places of insertion of Nursing in Collective Health.